Sol_75H71026Q00253_Amd_0001.pdf

(x)

75H71026Q00253 x x

1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted ; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR

OFFER. If by virtue of this amendment you desire to change an offer already submitted , such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

x

Kayenta AZ 86033

Highway 160, Mile Post 394.3 PO Box 368 Acquisition Department Kayenta Health Center

08/21/20260001

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.is extended, Items 8 and 15, and returning

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended , by one of the following methods: (a) By completing

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9B. DATED (SEE ITEM 11)

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

08/19/2026

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation data, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

**THIS IS AN INDIAN-OWNED SMALL BUSINESS ECONOMIC ENTERPRISE (ISBEE) SET-ASIDE**

This solicitation 75H71026Q00253 is hereby amended to reflect the following changes:

--Attach Section A of SF-1449 form

--Attach Q&A Form

--Update clauses pertaining to Privacy and Limitations on Subcontracting

--Add site visit: 09/02/2026 at 10:00AM MDT

--The solicitation's closing date/time is extended FROM 08/31/2026 @ 04:00PM (MDT) TO

09/04/2026 @ 4:00PM (MDT)

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

MICHELLE A. JAMES

STANDARD FORM 30 (REV. 11/2016)

Prescribed by GSA FAR (48 CFR) 53.243

Previous edition unusable

Except as provided herein, all terms and conditions of the document referenced in Item 9 A or 10A, as heretofore changed, remains unchanged and in full force and effect .

SEE ADDENDUMIS CHECKED

CODE 18a. PAYMENT WILL BE MADE BY

CODE

FACILITYCODE

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER

OFFEROR

Highway 160, Mile Post 394.3 PO Box 368 Acquisition Department Kayenta Health Center

CODE 16. ADMINISTERED BYCODE

X

X

561621

SIZE STANDARD:

% FOR:SET ASIDE:UNRESTRICTED OR25

RFPIFB

10. THIS ACQUISITION ISCODE

RFQ

14. METHOD OF SOLICITATION

13b. RATING

NAICS:

SMALL BUSINESS

08/31/2026 1600 MT

08/19/2026

BRANDON MARTINEZ

(No collect calls)

INFORMATION CALL:

FOR SOLICITATION 8. OFFER DUE DATE/LOCAL TIMEb. TELEPHONE NUMBER a. NAME

4. ORDER NUMBER3. AWARD/ 6. SOLICITATION

75H71026Q00253

5. SOLICITATION NUMBER

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS 1. REQUISITION NUMBER PAGE OF

1 51 OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

Kayenta AZ 86033

TELEPHONE NO.

17a. CONTRACTOR/

Kayenta AZ 86033 Highway 160 Mile Post 394.3 Kayenta Health Center

15. DELIVER TO

Kayenta AZ 86033 Highway 160, Mile Post 394.3 PO Box 368 Acquisition Department

9. ISSUED BY

7.

2. CONTRACT NO.

EFFECTIVE DATE

$25

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW

ISSUE DATE

DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

11.

SEE SCHEDULEX

12. DISCOUNT TERMS

THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13a.

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

8(A)

Kayenta Health Center

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

**THIS IS AN INDIAN-OWNED SMALL BUSINESS ECONOMIC

ENTERPRISE (ISBEE) SET-ASIDE**

This contract is subject to the electronic payment process by the Department of Treasury.

All invoices complying to the requirements at 52.212-4(g) must be submitted through www.ipp.gov. For additional information, refer to the incorporated clause at 352.232-71 Electronic Submission of Payment Requests (APR 2026

DEVIATION).

(Use Reverse and/or Attach Additional Sheets as Necessary)

HEREIN, IS ACCEPTED AS TO ITEMS:

XX

DATED

JERLYN R. BEGAY

. YOUR OFFER ON SOLICITATION (BLOCK 5),

INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE SET FORTH

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND DELIVER

ARE

ARE

31c. DATE SIGNED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER)

30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (Type or print)

ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY ADDITIONAL

SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

26. TOTAL AWARD AMOUNT (For Govt. Use Only)

OFFER

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA - FAR (48 CFR) 53.212

ARE NOT ATTACHED.

ARE NOT ATTACHED.

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

30b. NAME AND TITLE OF SIGNER (Type or print)

30a. SIGNATURE OF OFFEROR/CONTRACTOR

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

25. ACCOUNTING AND APPROPRIATION DATA

29. AWARD OF CONTRACT:

REF.

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32c. DATE 32b. SIGNATURE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED:

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

40. PAID BY39. S/R VOUCHER NUMBER38. S/R ACCOUNT NUMBER

37. CHECK NUMBER

FINALPARTIAL

36. PAYMENT

FINALPARTIAL

35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER33. SHIP NUMBER

COMPLETE

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

42d. TOTAL CONTAINERS42c. DATE REC'D (YY/MM/DD)

42b. RECEIVED AT (Location)

42a. RECEIVED BY (Print)

41c. DATE41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

STANDARD FORM 1449 (REV. 2/2012) BACK

24.

AMOUNT

23.

UNIT PRICE

22.

UNIT

21.

QUANTITY

20.

SCHEDULE OF SUPPLIES/SERVICES

19.

ITEM NO.

If the Government's and Contractor's terms and conditions are in conflict, the Government's terms and conditions shall prevail.

1 The Contractor shall provide all labor, materials, equipment, programming, testing, and technical support necessary to install, configure, test, and place into operation a complete pharmacy Intrusion Detection System

(IDS) for the Pharmacy Dept at Kayenta Service

Unit, in accordance with Attachment A - Statement of Work (SOW).

Labor Cost

2 Materials & Equipment

DMP Intrusion Detection Panel Elevation

Part No.: DMP XR550DNL-G (XR550 Network & Dialer

Panel in Large Enclosure)

Quantity: 1

Below Ceiling Motion Sensor

Continued ...

32f. TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT REPRESENTATIVE

51 2 of

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

3 51

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

(A) (B) (C) (D) (E) (F)

75H71026Q00253

Part No.: Bosch DS939 360-degree Motion Sensor

Quantity: 16

High Security Door Contact, Level II

Part No.: HSS-L2D-000 High Security Switch

Quantity: 8

7160-W Intrusion Arm/Disarm Keypad

Part No.: DMP 7160 Alternate Design Green

LCDArm/Disarm Keypad, Quantity: 3

Intrusion Detection System - Duress Button

Part No.: HUSD-15BL (Dual button Duress Switch)

Quantity: 2

3 Traveling & Lodging Expenses

NSN 7540-01-152-8067 OPTIONAL FORM 336 (4-86)

Sponsored by GSA

FAR (48 CFR) 53.110

Rev. 04/29/2026

SECTION B – CONTINUATION OF SF-1449

This page has been left blank intentionally.

SECTION C – CONTRACT CLAUSES

52.212-4 CONTRACT TERMS AND CONDITIONS –

COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

The following Federal Acquisition Regulation clauses also apply:

☐ 52.203-3 GRATUITIES APR 1984

☐ 52.203-6 RESTRICTIONS ON SUBCONTRACTOR SALES TO THE GOVERNMENT Alt I

NOV 2021

☐ 52.203-12 LIMITATION OF PAYMENTS TO INFLUENCE CERTAIN FEDERAL

TRANSACTIONS

JUN 2020

☐ 52.203-13 CONTRACTOR CODE OF BUSINESS ETHICS AND CONDUCT NOV 2021

☐ 52.203-16 PREVENTING PERSONAL CONFLICTS OF INTEREST JUN 2020

☒ 52.203-17 CONTRACTOR EMPLOYEE WHISTLEBLOWER RIGHTS NOV 2023

☒ 52.203-19 PROHIBITION ON REQUIRING CERTAIN INTERNAL CONFIDENTIALITY

AGREEMENTS OR STATEMENTS

JAN 2017

☐ 52.204-9 PERSONAL IDENTITY VERIFICATION OF CONTRACTOR PERSONNEL JAN 2011

☒ 52.204-13 SYSTEM FOR AWARD MANAGEMENT MAINTENANCE NOV 2025

(DEVIATION)

☐ 52.204-14 SERVICE CONTRACT REPORTING REQUIREMENTS NOV 2025

(DEVIATION)

☐ 52.204-15 SERVICE CONTRACT REPORTING REQUIREMENTS FOR INDEFINITE-

DELIVERY CONTRACTS

NOV 2025

(DEVIATION)

☐ 52.204-91 CONTRACTOR IDENTIFICATION NOV 2025

(DEVIATION)

☒ 52.209-6 PROTECTING THE GOVERNMENT’S INTEREST WHEN

SUBCONTRACTING WITH CONTRACTORS DEBARRED, SUSPENDED, OR

PROPOSED FOR DEBARMENT

NOV 2025

(DEVIATION)

☐ 52.209-9 UPDATES OF PUBLICLY AVAILABLE INFORMATION REGARDING

RESPONSIBILITY MATTERS

NOV 2025

(DEVIATION)

☒ 52.209-10 PROHIBITION ON CONTRACTING WITH INVERTED DOMESTIC

CORPORATIONS

NOV 2025

(DEVIATION)

☐ 52.213-1 RESERVED

☐ 52.219-3 NOTICE OF HUBZONE SET-ASIDE OR SOLE-SOURCE AWARD NOV 2025

(DEVIATION)

☐ 52.219-6 NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE NOV 2025

(DEVIATION)

☐ 52.219-6 Alt I

NOTICE OF TOTAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I NOV 2025

(DEVIATION)

☐ 52.219-7 NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE NOV 2020

☐ 52.219-7 Alt I

NOTICE OF PARTIAL SMALL BUSINESS SET-ASIDE, WITH ALTERNATE I MAR 2020

☐ 52.219-8 UTILIZATION OF SMALL BUSINESS CONCERNS NOV 2025

(DEVIATION)

☐ 52.219-9 SMALL BUSINESS SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

☐ 52.219-9 Alt I

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE I NOV 2025

(DEVIATION)

☐ 52.219-9 Alt II

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE II NOV 2025

(DEVIATION)

☐ 52.219-9 Alt III

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE III NOV 2025

(DEVIATION)

☐ 52.219-9 Alt IV

SMALL BUSINESS SUBCONTRACTING PLAN, WITH ALTERNATE IV NOV 2025

(DEVIATION)

☐ 52.219-13 NOTICE OF SET-ASIDE OF ORDERS MAR 2020

☐ 52.219-13 Alt I

RESERVED

☐ 52.219-16 LIQUIDATED DAMAGES—SUBCONTRACTING PLAN NOV 2025

(DEVIATION)

☐ 52.219-27 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, SERVICE-

DISABLED VETERAN-OWNED SMALL BUSINESS (SDVOSB) CONCERNS

ELIGIBLE UNDER THE SDVOSB PROGRAM

NOV 2025

(DEVIATION)

☒ 52.219-28 POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION NOV 2025

(DEVIATION)

☐ 52.219-28 Alt I

POSTAWARD SMALL BUSINESS PROGRAM REREPRESENTATION, WITH

ALTERNATE I

NOV 2025

(DEVIATION)

☐ 52.219-29 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO,

ECONOMICALLY DISADVANTAGED WOMEN-OWNED SMALL BUSINESS

CONCERNS

NOV 2025

(DEVIATION)

☐ 52.219-30 NOTICE OF SET-ASIDE FOR, OR SOLE-SOURCE AWARD TO, WOMEN-

OWNED SMALL BUSINESS CONCERNS ELIGIBLE UNDER THE WOMEN-

OWNED SMALL BUSINESS PROGRAM

NOV 2025

(DEVIATION)

☐ 52.219-33 NONMANUFACTURER RULE NOV 2025

(DEVIATION)

☒ 52.222-3 CONVICT LABOR NOV 2025

(DEVIATION)

☒ 52.222-19 CHILD LABOR—COOPERATION WITH AUTHORITIES AND REMEDIES NOV 2025

(DEVIATION)

☐ 52.222-35 EQUAL OPPORTUNITY FOR VETERANS NOV 2025

(DEVIATION)

☒ 52.222-36 EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES NOV 2025

(DEVIATION)

☐ 52.222-36

ALT I

EQUAL OPPORTUNITY FOR WORKERS WITH DISABILITIES, WITH

ALTERNATE I

JUL 2014

☐ 52.222-37 EMPLOYMENT REPORTS ON VETERANS NOV 2025

(DEVIATION)

☐ 52.222-40 NOTIFICATION OF EMPLOYEE RIGHTS UNDER THE NATIONAL LABOR

RELATIONS ACT

NOV 2025

☐ 52.222-41 SERVICE CONTRACT LABOR STANDARDS NOV 2025

(DEVIATION)

☐ 52.222-43 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT (MULTIPLE YEAR AND OPTION

CONTRACTS)

NOV 2025

(DEVIATION)

☐ 52.222-44 FAIR LABOR STANDARDS ACT AND SERVICE CONTRACT LABOR

STANDARDS-PRICE ADJUSTMENT

NOV 2025

(DEVIATION)

☒ 52.222-50 COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

☐ 52.222-50 Alt I

COMBATING TRAFFICKING IN PERSONS NOV 2025

(DEVIATION)

☐ 52.222-51 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR MAINTENANCE, CALIBRATION, OR

REPAIR OF CERTAIN EQUIPMENT—REQUIREMENTS

NOV 2025

(DEVIATION)

☐ 52.222-53 EXEMPTION FROM APPLICATION OF THE SERVICE CONTRACT LABOR

STANDARDS TO CONTRACTS FOR CERTAIN SERVICES—

REQUIREMENTS

NOV 2025

(DEVIATION)

☐ 52.222-54 EMPLOYMENT ELIGIBILITY VERIFICATION NOV 2025

(DEVIATION)

☐ 52.222-55 MINIMUM WAGES FOR CONTRACTOR WORKERS UNDER EXECUTIVE

ORDER 14026

NOV 2025

(DEVIATION)

☐ 52.222-62 PAID SICK LEAVE UNDER EXECUTIVE ORDER 13706 NOV 2025

(DEVIATION)

☒ 52.222-90 ADDRESSING DEI DISCIMINATION BY FEDERAL CONTRACTORS APR 2026

(DEVIATION)

☐ 52.223-2 REPORTING OF BIOBASED PRODUCTS UNDER SERVICE AND

CONSTRUCTION CONTRACTS

NOV 2025

(DEVIATION)

☒ 52.223-5 POLLUTION PREVENTION AND RIGHT-TO-KNOW INFORMATION MAY 2024

☐ 52.223-11 OZONE-DEPLETING SUBSTANCES NOV 2025

(DEVIATION)

☐ 52.223-12 MAINTENANCE, SERVICE, REPAIR, OR DISPOSAL OF REFRIGERATION

EQUIPMENT AND AIR CONDITIONERS

NOV 2025

(DEVIATION)

☒ 52.223-23 SUSTAINABLE PRODUCTS NOV 2025

(DEVIATION)

☐ 52.224-1 PRIVACY ACT NOTIFICATION APR 1984

☐ 52.224-2 PRIVACY ACT APR 1984

☐ 52.224-3 PRIVACY TRAINING JAN 2017

☐ 52.224-3

ALT I

PRIVACY TRAINING, WITH ALTERNATE I JAN 2017

☐ 52.225-1 BUY AMERICAN-SUPPLIES NOV 2025

(DEVIATION)

☐ 52.225-1 Alt I

BUY AMERICAN-SUPPLIES, WITH ALTERNATE I OCT 2022

☒ 52.225-3 BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT NOV 2025

52.225-3

ALT I

RESERVED

☐ 52.225-3 Alt II

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE II

NOV 2025

(DEVIATION)

☐ 52.225-3 Alt III

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE III

NOV 2025

(DEVIATION)

☐ 52.225-3 Alt IV

BUY AMERICAN-FREE TRADE AGREEMENTS-ISRAELI TRADE ACT,

WITH ALTERNATE IV

NOV 2025

(DEVIATION)

☐ 52.225-5 TRADE AGREEMENTS NOV 2023

☐ 52.225-14 INCONSISTENCY BETWEEN ENGLISH VERSION AND TRANSLATION OF

CONTRACT

FEB 2000

☐ 52.225-19 CONTRACTOR PERSONNEL IN A DESIGNATED OPERATIONAL AREA OR

SUPPORTING A DIPLOMATIC OR CONSULAR MISSION OUTSIDE THE

UNITED STATES

MAY 2020

☐ 52.225-26 CONTRACTORS PERFORMING PRIVATE SECURITY FUNCTIONS

OUTSIDE THE UNITED STATES

OCT 2016

☒ 52.226-1 UTILIZATION OF INDIAN ORGANIZATIONS AND INDIAN-OWNED

ECONOMIC ENTERPRISES

NOV 2025

(DEVIATION)

☐ 52.226-5 RESTRICTIONS ON SUBCONTRACTING OUTSIDE DISASTER OR

EMERGENCY AREA

NOV 2025

(DEVIATION)

☐ 52.226-6 PROMOTING EXCESS FOOD DONATION TO NONPROFIT

ORGANIZATIONS

NOV 2025

(DEVIATION)

☐ 52.226-7 DRUG-FREE WORKPLACE MAY 2024

☒ 52.226-8 ENCOURAGING CONTRACTOR POLICIES TO BAN TEXT MESSAGING

WHILE DRIVING

MAY 2024

☐ 52.229-12 TAX ON CERTAIN FOREIGN PROCUREMENTS AUG 2025

(DEVIATION)

☐ 52.232-18 AVAILABILITY OF FUNDS APR 1984

☐ 52.232-29 TERMS FOR FINANCING OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

☐ 52.232-30 INSTALLMENT PAYMENTS OF COMMERCIAL PRODUCTS AND

COMMERCIAL SERVICES

NOV 2021

☒ 52.232-33 PAYMENT BY ELECTRONIC FUNDS TRANSFER—SYSTEM FOR AWARD

MANAGEMENT

OCT 2018

☐ 52.232-34 PAYMENT BY ELECTRONIC FUNDS TRANSFER—OTHER THAN SYSTEM

FOR AWARD MANAGEMENT

JUL 2013

☐ 52.232-36 PAYMENT BY THIRD PARTY NOV 2025

(DEVIATION)

☒ 52.232-40 PROVIDING ACCELERATED PAYMENTS TO SMALL BUSINESS

SUBCONTRACTORS

MAR 2023

☐ 52.232-90 FAST PAYMENT PROCEDURE NOV 2025

(DEVIATION)

☒ 52.233-3 PROTEST AFTER AWARD NOV 2025

(DEVIATION)

☒ 52.233-4 APPLICABLE LAW FOR BREACH OF CONTRACT CLAIM NOV 2025

☒ 52.237-2 PROTECTION OF GOVERNMENT BUILDING, EQUIPMENT, AND

VEGETATION

APR 1984

☐ 52.237-3 CONTINUITY OF SERVICES JAN 1991

☒ 52.240-91 SECURITY PROHIBITIONS AND EXCLUSIONS NOV 2025

(DEVIATION)

☐ 52.240-91 Alt I

SECURITY PROHIBITIONS AND EXCLUSIONS, WITH ALTERNATE I NOV 2025

(DEVIATION)

☐ 52.240-92 SECURITY REQUIREMENTS NOV 2025

(DEVIATION)

☐ 52.240-92 Alt II

SECURITY REQUIREMENTS WITH ALTERNATE II NOV 2025

(DEVIATION)

☐ 52.240-93 BASIC SAFEGUARDING OF COVERED CONTRACTOR INFORMATION

SYSTEMS

NOV 2025

(DEVIATION)

☐ 52.242-5 PAYMENTS TO SMAL BUSINESS SUBCONTRACTORS JAN 2017

☐ 52.242-13 BANKRUPTCY JUL 1995

☐ 52.244-2 SUBCONTRACTS JUN 2020

☒ 52.244-6 SUBCONTRACTS FOR COMMERCIAL PRODUCTS AND COMMERCIAL

SERVICES

NOV 2025

(DEVIATION)

☐ 52.245-1 GOVERNMENT PROPERTY SEP 2021

☐ 52.245-2 GOVERNMENT PROPERTY INSTALLATION OPERATION SERVICES APR 2012

☐ 52.245-9 USE AND CHARGES APR 2012

☐ 52.247-64 PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS

NOV 2025

(DEVIATION)

☐ 52.247-64 Alt I

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE I

APR 2003

☐ 52.247-64 Alt II

PREFERENCE FOR PRIVATELY OWNED U.S.-FLAG COMMERCIAL

VESSELS, WITH ALTERNATE II

NOV 2021

52.219-14 LIMITATIONS ON SUBCONTRACTING NOV 2025

(a) This clause does not apply to the unrestricted portion of a partial set-aside.

(b) Definition. Similarly situated entity, as used in this clause, means a first-tier subcontractor, including an independent contractor, that—

(1) Has the same small business program status as that which qualified the prime contractor for the award (e.g., for a small business set-aside contract, any small business concern, without regard to its socioeconomic status); and

(2) Is considered small for the size standard under the North American Industry Classification System (NAICS) code the prime contractor assigned to the subcontract.

(c) Applicability. This clause applies only to—

(1) Contracts that have been set aside for any of the small business concerns identified in 19.000(a)(3);

(2) Part or parts of a multiple-award contract that have been set aside for any of the small business concerns identified in 19.000(a)(3);

(3) Contracts that have been awarded on a sole-source basis in accordance with subparts 19.105, 19.106, 19.107, and 19.108;

(4) Orders expected to exceed the simplified acquisition threshold and that are set aside for small business concerns under multiple-award contracts, as described in 8.4 and 16.5;

(5) Orders, regardless of dollar value, that are set aside in accordance with section 19.105, 19.106, 19.107, and 19.108 under multiple-award contracts, as described in 8.4 and 16.5; and

(6) Contracts using the HUBZone price evaluation preference to award to a HUBZone small business concern unless the concern waived the evaluation preference.

(d) Independent contractors. An independent contractor shall be considered a subcontractor.

(e) By submission of an offer and execution of a contract, the Contractor agrees that in performance of a contract assigned a North American Industry Classification System (NAICS) code for—

(1) Services (except construction), it will not pay more than 50 percent of the amount paid by the Government for contract performance to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 50 percent subcontract amount that cannot be exceeded. When a contract includes both services and supplies, the 50 percent limitation shall apply only to the service portion of the contract;

(2) Supplies (other than procurement from a nonmanufacturer of such supplies), it will not pay more than 50 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 50 percent subcontract amount that cannot be exceeded. When a contract includes both supplies and services, the 50 percent limitation shall apply only to the supply portion of the contract;

(3) General construction, it will not pay more than 85 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 85 percent subcontract amount that cannot be exceeded; or

(4) Construction by special trade contractors, it will not pay more than 75 percent of the amount paid by the Government for contract performance, excluding the cost of materials, to subcontractors that are not similarly situated entities. Any work that a similarly situated entity further subcontracts will count towards the prime contractor's 75 percent subcontract amount that cannot be exceeded.

(f) The Contractor shall comply with the limitations on subcontracting as follows:

(1) For contracts, in accordance with paragraphs (c)(1), (2), (3) and (6) of this clause—

☐ By the end of the base term of the contract and then by the end of each subsequent option period; or https://www.acquisition.gov/far/part-19#FAR_19_000 https://www.acquisition.gov/far/part-19#FAR_19_000

☒ By the end of the performance period for each order issued under the contract.

(2) For orders, in accordance with paragraphs (c)(4) and (5) of this clause, by the end of the performance period for the order.

(g) A joint venture agrees that, in the performance of the contract, the applicable percentage specified in paragraph (e) of this clause will be performed by the aggregate of the joint venture participants.

(1) In a joint venture comprised of a small business protégé and its mentor approved by the Small Business Administration, the small business protégé shall perform at least 40 percent of the work performed by the joint venture. Work performed by the small business protégé in the joint venture must be more than administrative functions.

(2) In an 8(a) joint venture, the 8(a) participant(s) shall perform at least 40 percent of the work performed by the joint venture. Work performed by the 8(a) participants in the joint venture must be more than administrative functions.

(End of Clause)

52.252-2 CLAUSES INCORPORATED BY REFERENCE FEB 1998

This contract incorporates one or more clauses by reference, with the same force and effect as if they were given in full text. Upon request, the Contracting Officer will make their full text available. Also, the full text of a clause may be accessed electronically at this/these address(es):

Revolutionary FAR Overhaul - FAR Overhaul - FAR Part Deviation Guidance | Acquisition.GOV

Federal Acquisition Regulation - https://www.acquisition.gov/browse/index/far

Department of Health and Human Services Acquisition Regulation – https://www.acquisition.gov/hhsar

(End of clause)

52.252-6 AUTHORIZED DEVIATIONS IN CLAUSES NOV 2020

(a)The use in this solicitation or contract of any Federal Acquisition Regulation (48 CFR Chapter 1) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the date of the clause.

(b)The use in this solicitation or contract of any Department of Health and Human Services (48 CFR Chapter 3) clause with an authorized deviation is indicated by the addition of "(DEVIATION)" after the name of the regulation.

(End of clause)

The following Department of Health and Human Services Acquisition Regulation clauses also apply:

☐ 352.203-70 ANTI-LOBBYING DEC 2015

☐ 352.208-70 PRINTING AND DUPLICATION DEC 2015

https://www.acquisition.gov/far-overhaul/far-part-deviation-guide https://www.acquisition.gov/browse/index/far https://www.acquisition.gov/hhsar

☐ 352.211-3 PAPERWORK REDUCTION ACT DEC 2015

☐ 352.219-71 MENTOR-PROTÉGÉ PROGRAM REPORTING REQUIREMENTS JAN 2010

☐ 352.223-70 SAFETY AND HEALTH DEC 2015

☐ 352.224-70 PRIVACY ACT DEC 2015

☒ 352.226-6 INDIAN ECONOMIC ENTERPRISE SUBCONTRACTING

LIMITATIONS

MAR 2022

☐ 352.227-70 PUBLICATIONS AND PUBLICITY DEC 2015

☐ 352.231-70 SALARY RATE LIMITATION DEC 2015

☐ 352.237-70 PRO-CHILDREN ACT DEC 2015

☐ 352.237-71 CRIME CONTROL ACT – REPORTING OF CHILD ABUSE DEC 2015

☐ 352.237-72 CRIME CONTROL ACT – REQUIREMENTS FOR BACKGROUND

CHECKS

DEC 2015

☐ 352.237-73 INDIAN CHILD PROTECTION AND FAMILY VIOLENCE ACT DEC 2015

352.232-71 ELECTRONIC SUBMISSION OF PAYMENT

REQUESTS

APR 2026

(a) Definitions. As used in this clause –

Payment request means a bill, voucher, invoice, or request for contract financing payment with associated supporting documentation. The payment request must comply with the requirements in FAR 32.905(b) and the applicable payment clause included in this contract.

(b) Submission instructions. Except as provided in paragraph (c) of this clause, the Contractor must submit payment requests electronically using the Department of Treasury Invoice Processing Platform (IPP) or successor system. Information regarding IPP, including IPP Customer Support contact information, is available at www.ipp.gov or any successor site.

(c) Alternate submission procedures. The Contractor may submit payment requests using other than IPP only when the Contracting Officer authorizes alternate procedures in writing.

(d) Submission of alternate payment procedures authorization. If alternate payment procedures are authorized, the Contractor shall include a copy of the Contracting Officer’s written authorization with each payment request.

(End of clause)

The following local Indian Health Service, Navajo Area terms also apply:

NAIHS-ACQ-07 PRE-CONSTRUCTION RISK ASSESSMENT AUG 2021

The Indian Health Manual, Part 1, Chapter 9 Occupational Safety and Health (OSH) Program (The Manual) serves as a general outline for carrying out the OSH program. The provisions set forth in The Manual meets or exceeds the minimum requirements as set forth in Title 29 Code of Federal Regulations, Part 1960, entitled “Basic Program Elements for Federal Employee OSH Programs and Related Matters,” Section 19 of the Occupational Safety and http://www.ipp.gov/

Health Act; and Executive Order 12196, dated February 26, 1980. While not specifically mentioned in the OSH related regulations, executive orders, program guidance, etc., it is in the Agency and in the public interest to afford the same conditions to visitors, patients, contractors, and others present in Indian Health Service facilities.

As part of the implementation of The Manual, the Kayenta Service Unit uses a guide and checklist known as the Pre-Construction Risk Assessment or PCRA. The PCRA – included in all solicitations and awards for construction and construction-related work on the premises – is completed by the government’s requiring activity, as coordinated with and approved by the facility’s Safety Program Office before any work on premises can proceed.

The following government personnel is responsible for the initiation and completion of the PCRA:

Name: Nathaniel Cottrill, Safety Officer

Department: Quality Management Department

NAIHS-ACQ-09 UNAUTHORIZED COMMITMENTS NOV 2025

(a) Definitions.

Contracting Officer means a person with the authority to enter into, administer, and/or terminate contracts and make related determination and findings.

Ratification means the act of approving an unauthorized commitment by an official who has the authority to do so.

Unauthorized Commitment (UAC) means an agreement that is not binding solely because the Government representative who made it lacked the authority to enter into that agreement on behalf of the Government.

(b) Policy.

The Government is not bound by agreements with, or contractual commitments made to, prospective contractors by individuals who do not have delegated contracting authority. Unauthorized commitments do not follow the appropriate process for the expenditure of Government funds. Consequently, the Government may not be able to ratify certain actions, putting a contractor at risk for taking direction from a Federal official other than the contracting officer (see FAR 1.403-2). Government employees responsible for unauthorized commitments are subject to disciplinary action. Contractors perform at their own risk when accepting direction from unauthorized officials. Failure to follow statutory and regulatory processes for the expenditure of Government funds is a very serious matter.

(c) Procedure.

Any agreement, modification, or change to a contractual agreement made by a government personnel who lack authority will be deemed an unauthorized commitment. The Government is not liable to the Contractor or under the terms of the contract, financially or otherwise – unless the unauthorized commitment successfully passes the ratification process.

The ratification process does not have any lead time, nor does the Government make any promise that an unauthorized commitment will be ratified and, therefore, the Contractor would be paid. The Contractor proceeds at its own risk if any of the terms of the contract are altered, changed, or modified without the written concurrence by a Contracting Officer.

NAIHS-ACQ-20 PROTECTING FEDERAL EMPLOYEES AND

THE PUBLIC FROM EXPOSURE TO TOBACCO

SMOKE IN THE FEDERAL WORKPLACE

APR 2026

In accordance with Executive Order 13058 “Protecting Federal Employees and the Public from Exposure to Tobacco Smoke in the Federal Workplace,” and the Assistant Secretary for Health memorandum “Prohibition of Tobacco Use in HHS Occupied Facilities,” the use of tobacco products, in any form, is strictly prohibited at IHS-operated properties including, but not limited to:

1. All interior and exterior spaces of IHS-operated properties.

2. All HIS-operated spaces in multi-tenant buildings.

3. All Government vehicles regardless of their location.

4. Private vehicles while on IHS property.

The IHS continues to recognize the value and efficacy of patients’ traditional beliefs and ceremonial practices. The use of tobacco products for ceremonial purposes is allowed in the designated traditional healing room, including any space designated for a ceremony, or in a patient’s hospital room.

To the maximum extent practicable, Contractor must notify the Contracting Officer’s Representative in advance of using tobacco products in a ceremony.

SECTION D – DOCUMENTS, EXHIBITS, ATTACHMENTS, ETC.

Attachment A – Statement of Work

Attachment B – Indian Health Service Buy Indian Act Indian Economic Enterprise Representation Form (IEE Form)

Attachment C – Kayenta Health Center (KHC) Map

Attachment D – Pre-Construction Risk Assessment

Statement of Work

Pharmacy Intrusion Detection System Installation and Configuration Services

Background

Kayenta Service Unit (KSU), Indian Health Service (IHS), requires the installation and configuration of an intrusion detection system (IDS) for the Pharmacy Department located at Kayenta Alternative Rural Hospital (KARH).

The purpose of this project is to enhance physical security and intrusion detection capabilities for the pharmacy area through the installation of an intrusion detection system capable of providing alarm notification to KSU Security personnel and designated law enforcement response entities.

The intrusion detection system shall support operational security requirements for controlled pharmacy areas and provide after-hours intrusion protection, duress alarm capability, motion detection, tamper protection, and system supervision.

This acquisition supports KSU operational security requirements and compliance with applicable healthcare facility security and safety standards, including pharmacy security requirements related to after-hours intrusion protection and alarm notification capability.

Scope The contractor shall provide all labor, supervision, materials, equipment, tools, transportation, programming, testing, documentation, and technical support necessary to furnish, install, configure, test, and place into operation a complete pharmacy intrusion detection system for KSU.

Services shall include installation of intrusion detection system components including, but not limited to:

• Intrusion detection control panel(s)

• Motion detection devices

• High-security door contacts

• Duress alarm devices

• Arm/disarm keypads

• Power supplies

• Backup batteries

• Associated low-voltage cabling

• System programming and configuration

• Functional testing and commissioning

Attachment A - Statement of Work

The contractor shall ensure the system is fully operational upon completion of installation and scalable to support future expansion if required by KSU.

Objectives

1. Enhance physical security for the KARH Pharmacy.

2. Provide intrusion detection and duress alarm capability for designated pharmacy areas.

3. Provide alarm notification capability to KSU Security personnel and designated law enforcement response entities.

4. Ensure system reliability during commercial power interruptions through standby battery backup.

5. Provide a fully functional and tested intrusion detection system integrated into KSU operational security procedures.

6. Support pharmacy security requirements for after-hours intrusion detection and alarm response.

7. Minimize disruption to facility operations during installation activities.

Task The contractor shall provide all labor, materials, equipment, supervision, transportation, and technical expertise necessary to complete the project.

All work shall be performed in accordance with applicable federal, state, tribal, and local requirements, including but not limited to:

• National Electrical Code (NEC/NFPA 70)

• Applicable low-voltage security system installation standards

• UL-listed equipment requirements

• Manufacturer installation requirements

• Applicable healthcare facility safety and security requirements

• Applicable pharmacy security requirements

Alarm communication and supervision functions shall be configured in accordance with applicable NFPA 72 signaling and supervision requirements where applicable to the intrusion detection system.

The contractor shall furnish and install a complete intrusion detection system for the KARH Pharmacy area including motion detection devices, high-security door contacts, duress alarm devices, arm/disarm keypads, standby batteries, associated communication modules, and low-voltage cabling.

All intrusion detection system equipment furnished under this contract shall be UL-listed.

Installation of intrusion detection devices on fire-rated doors, frames, or assemblies shall not compromise the fire rating, operation, latching, or integrity of the fire door assembly.

The intrusion detection system shall be configured to generate alarm notifications to designated KSU Security personnel and designated law enforcement response entities upon alarm activation.

KSU Security shall maintain operational monitoring and response responsibilities.

The intrusion detection system shall:

• Perform daily communication supervision/testing

• Monitor system operational status

• Provide a minimum of 24-hour standby battery backup capability during commercial power interruptions

• Include tamper protection for intrusion detection system enclosures and devices

The contractor shall provide and install all low-voltage cabling necessary for system operation.

Contractor shall properly support all above-ceiling cabling and devices in accordance with applicable code requirements and manufacturer installation requirements.

Ceiling tiles removed or disturbed during installation activities shall be returned to original condition upon completion of work.

Upon completion of installation, the contractor shall perform complete functional testing and commissioning of the intrusion detection system.

The contractor shall provide:

• Product data and equipment specifications

• System programming documentation

• As-built drawings

• Operation and maintenance manuals

• Testing and commissioning documentation

• Warranty documentation

The contractor shall provide a minimum one (1) year warranty covering intrusion detection system equipment, workmanship, and installation.

The contractor shall provide operational training for designated KSU personnel upon completion of installation.

Delivery Installation activities shall be coordinated with KSU to minimize disruption to pharmacy and facility operations.

Contractor shall comply with applicable KSU Infection Control Risk Assessment (ICRA) and Pre-Construction Risk Assessment (PCRA) requirements prior to and during installation activities.

Contractor shall coordinate all above-ceiling work and ceiling tile removal activities with KSU Facilities Management, Infection Control, and applicable department representatives prior to performing work.

Contractor shall maintain work areas in a clean and orderly condition throughout the project and shall clean and remove dust, debris, packaging materials, cabling waste, ceiling tile debris, and other installation-related materials from work areas at the completion of daily activities and upon project completion.

Contractor shall implement appropriate dust control and containment measures as required by the approved

ICRA/PCRA.

Government-Furnished Property/Equipment KSU will provide reasonable access to installation areas and existing facility infrastructure as necessary for completion of work.

KSU will not provide contractor tools, equipment, low-voltage cabling materials, or installation supplies.

Security Requirements Contractor personnel shall comply with all applicable KSU security requirements.

Contractor personnel shall:

• Coordinate access with designated KSU personnel

• Wear visible identification while on Government property

• Comply with facility access restrictions

• Follow pharmacy security procedures

• Sign in and out as required

The Government reserves the right to deny facility access to contractor personnel who fail to comply with security requirements.

Place of Performance Kayenta Alternative Rural Hospital (KARH) Kayenta Service Unit Kayenta, Arizona

Period of Performance The period of performance shall consist of:

• Base Period: Date of Award through project completion

The contractor shall coordinate installation scheduling with KSU following award.

DEPARTMENT OF HEALTH & HUMAN SERVICES

Indian Health Service

Office of Management Services Division of Acquisition Policy (DAP)

5600 Fishers Lane Rockville, MD 20857

INDIAN HEALTH SERVICE

BUY INDIAN ACT

INDIAN ECONOMIC ENTERPRISE

REPRESENTATION FORM

SOLICITATION/SOURCES SOUGHT/RFI #: _________________________________________________

PROJECT TITLE: ________________________________________________________

DATE: ___________________________________________________________________

In accordance with 25 U.S.C. 47 the Buy Indian Act, the signature below constitutes self-certification that the Offeror meets the definition of an “Indian Economic Enterprise” (HHSAR 326.601) in response to this Sources Sought Notice, Request for Information (RFI) or Solicitation and resultant contract.

The enterprise must meet the definition of “Indian Economic Enterprise” throughout the following time periods:

(1) At the time an offer is made in response to this solicitation;

(2) At the time of contract award; and

(3) During the full term of the contract performance period. At any point during these periods, if the Contractor no longer meets the eligibility requirements, the contractor must provide immediate written notification to the Contracting Officer.

Individual Contracting Officers may require documentation of eligibility before awarding a set-aside or sole source contracts under the Buy Indian Act and awards may be subject to protest if the eligibility of the successful Offeror is in question. In addition to the self-certification requirements, successful Offerors must also be registered with the System of Award Management (SAM).

Any false or misleading information submitted by an enterprise when submitting an offer in consideration of an award set-aside under the authority of the Buy Indian Act is a violation of the law and punishable under 18 U.S.C. 1001.

False claims submitted as part of contract performance are subject to the penalties enumerated in 31 U.S.C. 3729 to 3731 and 18 U.S.C. 287.

REPRESENTATION

The Offeror represents as part of its offer that it does _____, does not _____ meet the definition of an “Indian Economic Enterprise” with “Indian Ownership” under the authority of the Buy Indian Act.

Name of the 51% owner of IEE Firm

Certifying Signature

Print Name

Name of Federally Recognized Tribal Entity

Business Name

DUNS Number

Attachment B - IEE Form

Duress Button

Duress Button

Arm/Disarm Keypad to located in the Security

Office

Legend

DMP Intrusion Detection Panel Elevation 1

Below Ceiling Motion Sensor 16

High Security Door Contact, Level II 8

7160-W Intrusion Arm/Disarm Keypad 3

Intrusion Detection System - Duress Button 2

Attachment C - KHC Map

08/14/18 Update

Pre-Construction Risk Assessment – Cover Page Project Title: Project/Contract #:

GIMC Coordinator: PCRA Submit Date:

Project Conducted by:

Fac. Mgmt. I.T. Telecom Clin. Eng.

Contractor: __________________________

Proposed Start Date:

Staff/Cont. Name: Est. Duration:

Supervisor Name: Est. Complete Date:

Telephone: Date Project Completed: Email:

Project Description: (include specific sites and tasks)

ICRA Classification Class I Class II Class III* Class IV*

Section 1. Initial Project Impact Review

Topic Will project negatively impact or involve…? No Yes Responses (If YES to any)

Fire Safety Section 2A(1)

Ceiling tile removal (less than 4 hours total) Complete Above the Ceiling Access Permit (ACAP) Existing fire-stop; minor barrier penetrations

Fire Safety Section 2A(2)

Fire detection/alarm/suppression systems Complete Interim Life Safety Measure (ILSM) evaluation. Exit paths or fire/smoke barriers

Hot work practices

Extra fire load or flammable materials

Utilities Section 2B

Water, sewer, electricity, steam, or HVAC (including outside air intakes)

Complete the Utility System Risk Assessment (USRA)

Medical gases or vacuum

Call systems, telephones, or IT systems

Environmental/ Occupational Section 2C

Lead or asbestos containing materials Complete Env./Occ. Risk Assessment (EORA) Chemical hazards (i.e. mercury, volatile organics)

Exposure to infectious agents or mold

Security Section 2D

Security systems (badge readers, cameras) Complete Security Risk Assessment (SRA) Security processes (tours, foot/vehicle traffic)

Infection Control Section 2E

Patient care areas or critical utilities Complete an Infection Control Risk Assessment (ICRA) Moderate to high levels of dust, noise, vibration

More than one work shift

Project Approval Evaluator Signature & Title Date: Required for: All

Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: USRA and ICRA

Supervisor (affected area) Date: Required for: All

Project Close-out Facility Manager Signature Date: Required for: All

Safety Officer Signature Date: Required for: All

Infection Preventionist Signature

Date: Required for: ICRA-Class III & IV

Supervisor (affected area) Date: Required for: All

Attachment D - Pre-Construction Risk Assessment

Section 2A(1). Above Ceiling Permit

Project Title: Project/Contract #:

Staff/Cont. Name: Start Date:

Supervisor Name: Estimated Duration:

Topic Issue for Evaluation No Yes Responses (If NO to any) Date Completed

GSU Training 1. Have all supervisors/workers been trained on fire safety requirements

Schedule training with Facility Mgr or Safety Ofcr

Review policy and sign acknowledgement below.

2. Has supervisor read above ceiling access policy?

Project Plans/ Drawings

1. Has a cable routing plan been provided to Facility Manager?

Provide Facility Mgr with written plan or drawing.

If req’d by Facility Mgr, request and redline Life Safety Plan drawings

2. Is a redlined drawing/CAD over the Life Safety Plan needed?

(GIMC use only)

Project Details 1. Have descriptions/fire ratings for any materials to be installed been provided?

Provide complete project details to Facility Manager; or utilize facility approved systems/materials.

2. Have additions of cables/wires to pre-existing pathways/sleeves been reviewed and found to comply with allowable loads?

3. Have descriptions of UL compliant firestop systems been provided; or will facility approved systems be used?

4. Have descriptions of approved hanger/ support systems been provided; or will facility approved systems be used?

5. Have product details for all firestop systems/materials been provided?

Pre-work inspection

1. Has a pre-work inspection been conducted?

Conduct pre-work inspection and notify Facility Manager of existing deficiencies.

2. Have any existing unprotected penetrations been identified?

3. Have existing items supported by sprinkler piping been identified?

ILSM 1. Will any ceiling/tile grid, fire/smoke barrier, or firestop system be compromised for more than 4 hours or beyond the end of the work day, without a temporary code compliant protection system/ methodology?

Conduct a full ILSM evaluation

ACA Permit Approval Facility Manager Signature Date:

ACA Permit Close-out

ABOVE CEILING ACCESS PERMIT

PERMIT MUST BE PROMINENTLY DISPLAYED AT THE JOB SITE

NOTICE TO PERMIT HOLDER

READ CAREFULLY

Certain spaces (such as above ceiling tile grids or utility closets) are restricted to authorized personnel, and are controlled in GSU facilities.

Access to these spaces is a privilege, which may be denied for those who do not comply with the Above Ceiling Access Permit Policy. This applies to all staff, as well as vendors and contractor personnel.

This form and the preceding pages are the permit and must be displayed at all times while creating new, or accessing existing penetrations in smoke or fire barriers. It must also be displayed when working above ceiling tile grids, in utility closets or in any other space identified as CONTROLLED SPACE.

Persons found working in these spaces without a valid permit visible are in violation of the ABOVE CEILING ACCESS PERMIT POLICY, and may lose their access privileges. Chronic non-compliers will be disciplined.

SOME EXAMPLES OF POLICY VIOLATIONS:

Accessing a controlled space without a permit

Failure to hold and display a valid permit

Failure to close out a permit

Performing work outside the scope of a permit

Providing false information to a permit issuer

Falsifying data on a permit

Allowing someone to work under the scope of a permit issued in another’s name

All individuals performing work in a CONTROLLED SPACE shall read and be familiar with the ABOVE CEILING ACCESS PERMIT POLICY, copies of which can be obtained in Facility Management.

I have read and understand the ABOVE CEILING ACCESS PERMIT POLICY, and agree to comply with it.

Staff/Contractor Signature Date:

Section 2A(2). Interim Life Safety Measure Risk Assessment

Project Title: Project/Contract #:

Topic Issue for Evaluation No Yes Responses (If YES to any) Date Initiated

Exits 1. Any exit access or travel distances altered/excessive? Post signage for an alternate means of egress Train staff on alternate means of egress* Inspect exit daily for blockage or debris Double fire drill frequency* Increase hazard surveys*

2. Any exits used by anyone other than contractors obstructed?

3. Absence of two remote exits?

Emergency Access

1. Access to emergency depts. or services obstructed? Designate an alternate means of access Notify GIMC Security Notify Gallup Fire Dept.

2. Access to construction area obstructed for emergency forces?

Fire Protection 1. Fire alarm/detection (>25% in one zone) impaired >4 hrs?

Submit fire watch request;

o Or, use/monthly test temp. alarm/detection/ suppression system

Notify Gallup Fire Dept.

Double fire drill frequency* Make affected staff aware

2. Fire suppression impaired >10 hrs?

Fire & Smoke Barriers

1. Major breaches of fire/smoke barriers (including vertical)?

Construct 1-hr smoke tight temp. barrier (as needed)

Inspect exits daily Double fire drill frequency Train staff to compensate*

2. Unprotected corridors or Haz. Areas?

3. Fire/smoke door maintenance/latching problem not immediately repairable?

Addl. Firefighting Equipment

1. Fire load significantly increased above normal for area/building?

Provide additional fire extinguishers in area

Addl. Firefighting Training

1. Additional firefighting equipment differs from normal equipment?

Train equipment staff/ contractors to use

Combustible Load Levels

1. New/increased storage of flammable/combustible materials? Minimize debris accumulation Increase hazard surveys

2. Flammable/combustible debris?

Hazard Surveillance

1. Addl. hazards such as excavations, etc.?

Initiate additional surveillance of area

Facility-wide Training

1. Life safety deficiencies or hazards impaired throughout entire building?

Train employees on ILSM Notify Gallup Fire Dept.

*-Need for response may be waived upon approval of Authority Having Jurisdiction based on scope and duration of project.

Describe any other life safety impacts, as well as specific actions to be implemented, for these and those above.

Evaluator signature & Title Date:

Safety Officer Signature Date:

Section 2A(3). Hot Work Permit

Project Title: Project/Contract #:

Section 2B. Utility System Risk Assessment

Project Title: Project/Contract #:

Will project affect? Yes No Minimum Recommended Precautions: (If Yes)

Noise

Review project and patient care schedules to identify least impactful times, or options to curtail or relocate patient care operations

Review how workers will access worksite and isolate from patient care as feasible Review tools and processes to be used for reasonable, quieter alternatives;

Install sound attenuating barriers where feasible. Monitor as needed.

Vibration Review work schedules for project and work area to identify least impactful times Review tools and processes to be used for reasonable alternatives Assess potential…