PWS Medical Surveillance.pdf

Performance Work Statement (PWS)

Civilian Air Traffic Control Specialist, Fire Department Emergency Services, and Public Health Medical Industrial Hygienist/ Environmental Health

Technician Examinations March ARB, California

1.0. Introduction.

1.1. Scope. This contract will serve as a vehicle to provide certified physicians who can perform health assessments and medical examinations required for the aforementioned civilian duty specific career fields. The frequency, scope, and applicability of the occupational health and medical examination will be determined by the Office of Personnel Management (OPM) Medical Standards and documented on applicable forms as indicated throughout this PWS for members at March Air Reserve Base, California.

1.2. Non-Personal Services. The services performed under this contract will be non-personal services and are not inherently governmental. The prime contractor’s staff, including all teaming partners, subcontractors, and their staff at the corporate level involved in the company’s or team’s administration of this contract, will hereafter be referred to as “contractor management staff.” The prime contractor retains responsibility for any teaming partner or subcontractor and will be accountable for their performance. The contractor management staff will provide all tools, labor, and materials required to recruit, qualify, train, place, manage, and retain the medical support services supporting healthcare operations for the Air Force in accordance with the terms and conditions of this contract.

1.3. Definitions.

Authorized Agency is/are an agency’s points of contact that is authorized to make appointments with the contractor. Those agencies are:

452 OSS/OSAB 452d Operations Support Squadron (Air Traffic Manager) 452 MSG/CEF 452d Mission Support Group, Civil Engineering Fire (Emergency Services)

452 MSG/SGPB 452d Mission Support Group, Public Health Contractor is a term used in this contract, which refers to the prime contractor.

Contracting Officer is a person with authority to enter into, administer or terminate contracts, and make related determinations and findings on behalf of the Government. Note: The only individual who can legally bind the Government.

Contracting Officer’s Representative (COR) is a person designated by the Contracting Officer as their representative whom manages the contract within its intended scope, terms, and conditions. Note: The COR does not have the authority to legally bind the Government.

Medical Surveillance Examination (MSE) is identified as pre-placement, periodic/annual, special purpose, termination, and fitness-for-duty examinations. Examinations are to be performed to assess the health status of individuals as it relates to their workplace assigned duties and/or essential job tasks.

Pre-placement examinations are tests and examinations accomplished to establish and document baseline medical status and capability required for specific job tasks and for future use in the evaluation of occupational health hazards from the workplace. These examinations are identified and directed by civilian personnel representatives and performed in accordance with federal directives to assess the health status of employees as it relates to the specific jobs they are applying for. If required, additional evaluations, laboratory tests and consultations to determine physical or emotional qualification (e.g., substance dependency, psychiatric disorder) will be accomplished to the extent required to determine final medical certification required to perform ATC duties and/or essential job tasks. (U.S. Office of Personnel Management Classification & Qualifications – General Schedule Qualifications Standards, Air Traffic Control Series, 2152, Medical Requirements: Initial Employment)1

Periodic/Annual Examinations are scheduled and performed annually thereafter. Annual medical examinations are performed to assess the health status and to re-qualify individual for employment as directed in the U.S. Office of Personnel Management Classification & Qualifications General Schedule Qualifications Standards, Air Traffic Control Series, 2152, Retention Requirements.1

Special Purpose Examinations are physical examinations given when an employee is exposed to a workplace hazard (environmental, chemical, biological or radiological) during an incident or accident.

Termination Examinations are tests and examinations that are accomplished to establish and document the health of employees at termination of employment.

Fitness-for-Duty Examinations are performed after an ATCS incurs an illness, injury, or incapacitation, at any time, between annual examinations. They must be medically cleared before returning to duty. If required, laboratory tests and consultations will be accomplished to determine medical clearance for continued duties and/or essential job tasks.

Principal Technical Contact for Medical Contractor. 452d Medical Group (452 MDG) representative will serve as the principal technical/medical contact with the medical contractor. The 452 MDG representative will provide advice and assistance, in concert with a Civilian Personnel representative, to the medical contractor in the application of policies, procedures, and clarification of official directives requirements.

1 https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/2100/air-traffic-control-series-2152/

1.4. Acronyms.

AFI Air Force Instruction CLIN Contract Line Item Number DD Department Defense DoD Department of Defense ECG Electrocardiogram ENT Ear Nose Throat FAA Federal Aviation Administration FEV Forced Expiratory Volume FSS/FSMC Civilian Personnel FSS/SGPB Bioenvironmental Engineering & Occupational-Public Health FVC Forced Vital Capacity HIPAA Health Insurance Portability and Accountability Act IRAPT Invoicing, Receipt, Acceptance, and Property Transfer NFPA National Fire Protection Association

OF Optional Form PH Public Health OPM U.S. Office of Personnel Management PFAS Per- and Polyfluoroalkyl Substances PFT Pulmonary Function Test PPE Personal Protective Equipment PTS Permanent Threshold Shift PWS Performance Work Statement SF Standard Form STD Standard STS Standard Threshold Shift TIG Technical Implementation Guide USAF United States Air Force WAWF Wide Area Work Flow

2.0. General Requirements. The contractor will ensure that medical services are performed by medical personnel that are licensed as directed under this contract.

2.1. Qualifications. The physician who provides medical services under this contract shall possess a valid current license to practice medicine in California. The physician:

(a) Must have graduated from an accredited medical school; and

(b) Have completed a residency program approved by the Council on Medical Education and Hospitals; and

(c) Have a current Aviation Medical Examiner’s (AME) certification; and

(d) Be qualified to perform Federal Aviation Administration (FAA) medical examinations; and

(e) Be board certified in either occupational medicine or preventive medicine by the American Board of Preventive Medicine or Osteopathic Council of Preventive Medicine.

2.2. Audiograms. Audiograms must be administered by an individual certified by the Council of Accreditation on Occupational Hearing Conservation (CAOHC). Technicians who perform audiograms must be responsible to an audiologist or physician.

2.3. Validation of Qualifications, Licensure and Certification (as applicable). The contractor shall provide written verification (and photocopies where necessary) showing licensor, board certification, hospital affiliation, and provide a statement of health to the contracting officer within 10 calendar days after contract award and prior to performing services of this contract. When a change in medical professional personnel is anticipated, the contractor shall provide the contracting office representative the same documentation for any replacement personnel as for original providers at least three weeks prior to the change taking place. All contracted management staff performing services for the Air Force have been trained and/or familiar with HIPAA Privacy & Security Rule and will be held accountable for complying with health information privacy and security policies and procedures. Reference HIPAA of 1996 for detailed language.

2.4. Health Insurance Portability and Accountability Act (HIPAA). All contracted management staff performing services for the Air Force have been trained and/or familiar with HIPAA Privacy & Security Rule and will be held accountable for complying with health information privacy and security policies and procedures. Reference HIPAA of 1996 for detailed language.

3.0. Description of Services.

3.1. Performance. The contractor will provide all personnel, equipment, materials, and facilities necessary to perform required tests and procedures to complete designated physical examinations.

All services will be for DoD civilian personnel assigned to March ARB, California. The contractor will perform all work in accordance with the PWS and this contract.

3.2. Location. All services will be executed at the contractor’s premises or within the Contractor’s network of facilities – affiliate or qualified subcontractor – which must be located within a 50 mile radius of March ARB, CA (zip code 92518).

3.3. Period of Performance and Annual Number of MSE. The period of performance for this PWS is for one (1) Base year from the date of contract award plus four (4) 12-month Options. The estimated number of DoD civilian ATCS employees requiring MSEs on an annual basis is 45-50 personnel. Fire Department personnel serviced by the contract will consist of an estimated 90 medical surveillance examinations on an annual basis. Public Health Medical Industrial Hygienist/Environmental Health Technicians served by this contract will be on as needed basis as only new-hire employees require a physical.

3.4. Medical Surveillance Examinations.

3.4.1. The contractor will conduct physical examinations and tests under this contract between the hours of 7:30 am and 4:30 pm PT, Monday through Friday. All recognized federal holidays are excluded and identified under Appendix B. Physicals may be scheduled outside of these hours with the consent of both parties to the contract.

3.4.2. Health examinations and tests will be performed in accordance with requirements which have been established by OPM and the FAA for a Second-Class Medical Certificate. Examinations will be conducted within five (5) calendar days after written or telephonic request from the authorized agency and documented on any or all of the below provided forms:

AF 1753 Hearing Conservation Examination AF2766 Clinical Occupational Health Exam Requirements.

DD 2215 Hearing Conservation – Reference Exam (Baseline) DD 2216 Hearing Conservation Data (Periodic) OF 78/OF 178 Certificate of Medical Examination SF 88 Report of Medical Examination SF 513 Medical Record Consultation Sheet

3.4.3. Physical examination techniques must comply or be equal to the examination requirements prescribed by any of the following directives:

AFI 48-123 Medical Examinations and Standards AFI 48-127 Air Force Hearing Conservation Program AFI 48-133 Physical Examination Techniques AFOSH Std 48-20 Air Force Hearing Conservation Program DoD 6055.05M Occupational Medical Examinations and Surveillance Manual 5 CFR 339.202 Medical Stds and Medical Evaluation Programs 5 CFR 339.205 Medical Evaluation Programs NFPA 1582-18 Standard Comprehensive Occupation Medical Program for Fire

Departments USAF TIG 1582-18 Technical Implementation Guide for NFPA1582- 18 5 CFR 339.202 Medical Stds and Medical Evaluation Programs 5 CFR 339.205 Medical Evaluation Programs

29 CFR Part 1910 OSHA Stds for General Industry, Subpart I, 1910.134 –Respiratory Protection

U.S. Office of Personnel Management Classification & Qualifications – General Schedule Qualification Standards, Air Traffic Control Series, 2152 (Initial Hire and Retention Requirements)

Federal Aviation Administration (FAA), Guide for Aviation Medical Examiners (AME) –Synopsis of Medical Standards for Second-Class Airman Medical Certificates

Air Traffic Control Tower Operators/Supervisors 14 CFR, Aeronautics & Space, Part 67 – Medical Standards and Certifications, Subpart C – Second-Class Airman Medical Certificates; Subpart E – Certification Procedures, 67.401 Special Issuance of Medical Certificates.

3.4.4. The contractor shall provide the 452 MDG representative a copy of all standards or guidelines used to interpret specific examinations and laboratory test results.

3.4.5. The approximate number of specific tests and number of tests required for each medical examination will be provided via email or through an Excel spreadsheet when the ATCS is scheduled for their medical exam appointment. The medical contractor will determine if the government employee meets existing physical requirements and medical standards as outlined in the OPM, FAA, and 14 CFR, Part 67 references as noted in paragraph 3.4.3.

3.4.6. When appropriate and IAW medical standards of the certifying organizations noted in paragraph 3.4.4 above, the AME may initiate a "Special Issuance of Medical Certificates (Authorization)" for an ATC Specialist who did not meet medical standards listed under subpart "C" of 14 CFR, Part 67. The AME accomplishing the medical examination will provide the Federal Air Surgeon (FAS) the documentation required to demonstrate the ATC Specialist can perform all duties authorized by the Second-Class medical certificate without endangering public safety, himself or co-workers. March ARB Air Traffic Control Center may, on average, require 6-8 Special Issuance of Medical Certificates (Authorizations) per year (12-month period).

NOTE: When non-occupational medical problems are identified and are not disqualifying for purposes of issuance of a FAA Second-Class Medical Certificate, the employee will be informed of the abnormality by contracting physician and advised to seek proper medical care from their personal medical care provider. If a non-occupational abnormality is remedial (e.g., otosclerosis) or is likely to be temporary (e.g., external otitis), but may interfere with the ability of the person to wear PPE such as hearing protection or unable to perform their duties, appropriate temporary duty restrictions will be recommended. The contractor physician determination as to whether the employee meets the physical requirements and medical standards will be documented on 1) FAA Form 8500-9 and 2) any appropriate forms identified in paragraph 3.4.2. of this PWS by the contractor.

3.4.7. Firefighter physical examinations must be in accordance with NFPA Std 1582-18 and Air Force

TIG 1582-18.

3.4.8. Examination requirements will include a PFT will include a FVC and FEV1 and FEV1/FVC Ratio.

3.4.9. The equipment must be of an approved type, as recommended by the American Thoracic Society, and be properly calibrated.

3.4.10. Persons, other than licensed contractor’s physicians, who administer the PFT will have completed a training course in spirometry sponsored by an appropriate academic or professional institution and be supervised by a physician.

3.4.11. The contractor will evaluate and make appropriate recommendations based on findings and indicate whether an employee is physically able to perform their work while wearing the prescribed respiratory protection.

3.4.12. The contractor will deliver all medical documentation in accordance with guidelines identified under section four (4) of this PWS.

3.4.13. The contractor will provide Perfluoroalkyl Substances (PFAS) biomonitoring for each firefighter during the Pre-Placement and Annual physical exams. Biomonitoring will consist of either serum or plasma, and will be collected and handled, in accordance with the processing laboratory’s special handling requirements. All PFAS samples must be processed by a licensed and accredited laboratory, offering specialized PFAS testing, for the purpose of biomonitoring. Contractor must provide the laboratory report, for each sample collected, by email, to the contracting office representative (COR), named in this document.

3.4.14. Public Health Duty Description: Individual serves as a health risk assessor, and an occupational and environmental health evaluator Functional Requirements: Light lifting, under 15 pounds, Reaching above shoulder, Use of fingers, Both hands required, Walking, Standing, Crawling, Kneeling, Ability to distinguish basic colors, Ability to distinguish shades of colors Hearing (aid may be permitted), Wear of Respirator – N95, 3M-7800, 3M-6000, MSA M-7 Firehawk.

Environmental Factors include: Outside and inside. Excessive heat. Excessive cold, Excessive humidity, Excessive dampness or chilling, Dry atmospheric conditions, Excessive noise, intermittent, Constant noise, Dust, Silica, asbestos, etc., Fumes, smoke, or gases, Solvents (degreasing agents), Grease and oils, Radiant energy, Electrical energy, Slippery or uneven walking surfaces, Working around machinery with moving parts, Working around moving objects or vehicles

3.5. Pre-placement, Special Purpose, Termination Examinations.

3.5.1. Pre-placement physical examinations will be performed within five (5) working days after receipt of written or telephonic request for appointment from the authorized agency.

3.5.2. The contractor will deliver all medical documentation in accordance with guidelines identified under Section 4 of this PWS.

3.6. Periodic Examinations.

3.6.1. Periodic physical examinations will be performed within five (5) working days after receipt of written or telephonic request for appointment from the authorized agency.

3.6.2. The contractor will deliver all medical documentation in accordance with guidelines

3.7. Fitness-for-Duty Examinations.

3.7.1. The Fitness-for-Duty exam is scheduled by a designated point of contact from the appropriate following organization: 452 OSS/OSAB, 452 MSG/CEF or 452 MSG/SGPB. All requirements for the physical will be listed on OF 78/178.

The physical will be accomplished within two (2) working days of receipt of written or telephonic request for appointment request from a designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1.

3.7.1.1. In cases where there is a question about physical/psychological fitness- for-duty, the Government has an immediate need to determine whether to remove the employee from the duty area; therefore, the physical exam will be accomplished as soon as possible.

The contractor physician will contact the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1 no later than (NLT) the morning of the next worday to provide diagnosis.

3.8. Audiograms.

3.8.1. The contractor will be responsible for performing audiograms in accordance with the standards specified within AFOSH STD 48-20.

3.8.2. Audiometric Environment and Audiometer Calibration.

3.8.2.1. Audiometric testing environment must be certified annually. The background octave band for Sound Pressure Levels (SPL) are not greater than the following standards listed in AFOSH STD 48-20, para

2.11.10.1. thru 2.11.10.5.:

For 500 Hertz (Hz), 27 dB For 4,000 Hz, 39 dB For 1,000 Hz, 29 dB For 8,000 Hz, 41 dB For 2,000 Hz, 34 dB

3.8.2.2. Audiometric Equipment Standards. Audiometers must comply with the standards of American National Standards Institute (ANSI) S3.6-2010 (or current STD). Audiometric testing room requirements are in ANSI S3.1-1999 (R2008), Maximum Permissible Ambient Noise Level for Audiometric Test Rooms.

3.8.2.3. Calibration, Testing, Daily Functional Checks, and Daily Calibration are explained in AFOSH STD 48- 20, para 4.9. thru 4.11. The Biomedical Equipment Technician or equivalent will ensure all calibrations and certifications are performed according to ANSI S1.4-1983 (R2006) and ANSI S3.1-1999 (R2008) or current ANSI standards. As a minimum, Daily Functional Checks will include listening for: crackling sounds, changes in loudness when moving the cord; presence of tones at all frequency settings, presence of tones only in the appropriate headset, and periods of silence while listening to frequency and attenuation changes. The Daily Calibration Check is performed every day that hearing tests are administered. An examiner who operates the audiometer must perform the calibration. The calibration test subject can be an electroacoustic ear or someone with known stable hearing levels.

3.8.2.4. Annual Acoustic Calibration. An acoustic calibration will be accomplished by a Biomedical Equipment Technician or an appropriate provider of these services annually, per 29 CFR 1910.95, Chapter XVII, Attachment E. Exhaustive Calibration is done every 2 years per sections 4.1 thru 4.5, ANSI S3.6- 2019 (or current ANSI Std). Only earphones meeting ANSI STD S3.6-2010 will be used in the AF HCP. Earphones must ONLY be used with the audiometer they were calibrated with.

3.8.3. The completed DD 2216 will serve as written notification of audiogram results. However, this does not preclude the contractor from providing other written patient disposition when warranted to describe the patient’s medical disposition.

3.8.4. Whenever a threshold shift has been verified by the second follow-up through audiometric testing will contact the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1 will provide the contractor with an AF 1753 The contractor will perform an examination of the employee using criteria found in 48-127 for Firefighters or, using the criteria found in AFOSH STD 48-20, para. 7 for Air Traffic Control Specialists, will determine whether a physiological problem caused the threshold shift. If so, notify will contact the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1.

3.8.5. A clinical examination of the ears, nose and throat will be performed by the contractor physician on all employees getting a reference audiogram check, those with STS, those required to be examined based on history and those undergoing a duty fitness and risk evaluation.

3.8.6. During the examination the contractor physician must note:

(1) Cerumen plugging the ear canals;

(2) Otitis external;

(3) Condition of the tympanic membranes;

(4) Any middle ear disease;

(5) Eustachian tube function;

(6) Any other ENT disease or condition, which might adversely affect the audiogram results; and,

(7) Any condition that may interfere with the wearing of hearing protection (permanently or temporarily).

3.8.7. Respirators – Initial Medical Evaluation for Firefighters only.

3.8.8. The contractor physician will review the provided OSHA respirator questionnaire, evaluate employee’s responses and make appropriate recommendations based on findings and indicate whether an employee is physically able to perform their work while wearing the prescribed respiratory protection. If additional testing is required, the contractor physician will coordinate the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1.

3.8.9. The contractor will deliver all medical documentation and appropriate forms (in paragraph, 3.4.3) in accordance with guidelines identified under section four (4) of this PWS.

3.9. The contractor will deliver all medical documentation and appropriate forms noted in paragraph

3.4.2. for ATC specialists and in paragraph 3.4.3 for Firefighters in accordance with guidelines

3.10. Final Assessment and Disposition.

3.10.1. The contractor physician will review all examination results and histories to make a final assessment and disposition.

3.10.2. All assessments and dispositions will be documented on the appropriate form identified in paragraph 3.4.2. of this PWS and all medical documentation will be delivered as identified under Section 4 of this PWS.

3.10.3. The contractor validates physical examination findings through verification of the original tests or any additional testing as prescribed by the attending contractor physician after telephonic coordination with the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1.. Further coordination/consultation will be acquired from the 452 FSS/FSMC concerning pre-placement and fitness-for-duty examinations.

3.10.4. The contractor physician will verbally notify the designated point of contact from one of the aforementioned 452 AMW organizations noted in 3.7.1 , no later than one (1) workday after the determination that a limiting condition exists or that removal from performance of air traffic control or firefighting duties is recommended or warranted.

3.11. Relationship of Parties.

3.11.1. It is expressly agreed and understood that the services rendered by the contractor and its employees are rendered in the capacity of an independent contractor. Although the government may evaluate the quality of both professional and administrative services for purposes of contract inspection and acceptance, it retains no control over the services rendered, including, but not limited to, professional judgments, diagnosis, or specific treatments.

3.11.2. The contractor will be solely responsible for any and all liability caused by the acts or omissions of its agents or employees.

3.12. Indemnification.

3.12.1. The contractor expressly agrees to indemnity, hold harmless, and to defend the government of the United States for all of its employees and agents acting officially or otherwise, from any and all liability, claims, demands, actions, debts, and attorney fees arising out of, claimed on account of, or in any manner predicated on loss or damage to the property of, injuries to, or death of any person whatsoever, which may occur as a result of or in connection with the services being provided under this contract.

4.0. Deliverables.

4.1. Standards, Guidelines, and References. The contractor will provide the the designated point of contact to one of the aforementioned 452 AMW organizations noted in 3.7.1 a current copy of all standards, guidelines and/or reference ranges used to interpret laboratory test results. Provide updates when changes occur.

4.2. Forms and Documentation. Contract physicians will complete required form(s) and/or documentation in accordance with the corresponding Air Force Instructions, NFPA 1582-18 (firefighters only), directives and policies identified in this PWS.

4.3. Reporting of Examination Results.

Type of Exam Organizations Delivered To Time Period

Pre-placement Fitness-for-Duty

452 OSS/OSAB

452 MSG/CEF

452 MSG/SGPB

Within 3 workdays after exam completion

Periodic/Annual Special Purpose Termination Audiograms Return to Duty Respirator Initial

452 OSS/OSAB

452 MSG/CEF

Within 3 workdays after exam completion

Medical 452 MSG/SGPB

4.3.1. For ATC specialists, all physical examination results that medically disqualify air traffic controllers, either temporarily or permanently, must be immediately reported via telephonic means t0 the Aircraft Traffic Manager, Bart Darnell452 OSS/OSAB at (951) 655-4848/4053 and email bart.darnell.1@us.af.mil. The Air Traffic Manager shall not permit air traffic personnel to control air traffic when temporarily or permanently medically disqualified in accordance with 14 CFR, Part 65.31(c). In addition, for employees with abnormal laboratory or ECG results that are not disqualifying, immediately notify the 452 OSS/OSAB at (951) 4848/4053 after receipt of results.

4.3.2. For Firefighters all physical examination results that medically disqualify employees and /or abnormal laboratory or ECG results must be telephoned todavid.shaw.5@us.af.mil, 452 MSG/CE, at

(951) 655-4851 and email dave.shaw.5@us.af.mil immediately after receipt.

4.3.3. For Public Health Medical Industrial Hygienist/Environmental Health Technicians, all physical examination results that medically disqualify employees and /or abnormal laboratory or ECG results must be telephoned to Mr. Marshall Prude at (951) 655-7156 and email marshall.prude@us.af.mil immediately after receipt.

4.3.4.

4.3.3. The contractor will note the date, time, and name of person contacted.

All examination results will be reported on any forms identified under paragraph 3.4.2 (with additional documents as necessary) and distributed with original file in the employee’s medical folder maintained at the contractor’s office.

4.3. Monthly Lists/Reports.

4.3.4. The contractor will provide the designated point of contact to one of the aforementioned 452 AMW organizations noted in 3.7.1a monthly list of all personnel examined and tests accomplished prior to invoicing within Wide Area Workflow (WAWF)/Invoice Receipt Acceptance and Property Transfer (IRAPT) or designated accounting system.

4.3.5. The list will be itemized for all tests administered to include the date and cost of each test per individual.

4.3.6. The contractor will annotate the monthly examination roster as follows:

mailto:marshall.prude@us.af.mil

Status Disposition

Completed Date Completed

No-Show Date and reason, if any, if the individual fails to meet their scheduled appointment

4.3.7. The contractor medical personnel will provide technical review of all examination data to ensure the highest level of quality control and accuracy of the completed medical surveillance examination. In addition, the contractor’s physician, nurse or technician will sign any form identified under paragraph 3.4.2 of this PWS provided by the member at the time of appointment as having provided a medical examination.

REFERENCES

(1) Privacy Act Statement

(2) Air Force Instruction (AFI) 48-123, Medical Examinations and Standards

(3) Air Force Occupational Safety and Health (AFOSH) Standard 48-20, Occupational Noise and Hearing Conservation Program

(4) DODI 6055.12, Hearing Conservation Program

(5) DODI 6055.05-M, Occupational Medical Examinations and Surveillance Manual

(6) 29 Code of Federal Regulations (CFR), Part 1910. 134, Respiratory Protection Appendix C – OSHA Respirator Medical Evaluation Questionnaire (Mandatory)

(7) U.S. Office of Personnel Management Classification & Qualifications General Schedule Qualifications Standards, Air Traffic Control Series, 2152 (Initial Hire and Retention Requirements)

(8) Federal Aviation Administration (FAA), Guide for Aviation Medical Examiners (AME) – Synopsis of Medical Standards for Second-Class Airman Medical Certificates – Air Traffic Control Tower Operators /Supervisors

(9) 14 CFR, Aeronautics & Space, Part 67 – Medical Standards and Certifications, Subpart C

– Second-Class Airman Medical Certificates; Subpart E – Certification Procedures,

67.401 Special Issuance of Medical Certificates

Appendices (2):

A. Medical Surveillance Examinations – Price Listing B. Medical Surveillance Examinations – Federal Holidays

APPENDIX A

MEDICAL SURVEILLANCE EXAMINATION

PRICE LISTING

BASE YEAR (CLIN 0001)

DESCRIPTION UNIT ESTIMATED

QUANTITY

UNIT

PRICE

TOTAL

COST

Pre-Placement: Med Hx; Comprehensive Med.

Eval – HEENT (Audiogram; Visual acuity, color);

Cardio-Pulmonary (ECG, PFT, CXR); GI & abdominal organs; Urinary, Reproductive Syst;

Spine, Axial skeleton, extremities; Neurological, Psychiatric disorders; Lab: CBC, LFT, ALT,UA, Lipid Panel, PFAS

Each 4

Annual (Age Specific):

Medical Hx, Exposure Hx Exam: HT, Wgt, BMI, VS (BP, HR, RR, Temp) HEENT, Neck, Cardio-Pulmonary, Abdominal Organs, GI, GU, Lymph Nodes, Skin, Hernia Ex, Labs: CBC, ALT, Lipid Panel, PFAS, Urine Dipstick; PFT, Audiometric Test, ECG; Visual Acuity, Color Perception, Confrontational Fields;

Each 54

Special Purpose Evals:

Cardio-Pulmonary (ECG, PFT, CXR); Skin Exam, HEENT – Vision, Audiometric test;

Musculoskeletal, Extremities; Neurologic. Lab:

HIV, Heavy Metals, UA/Micro-scopic;

Each 5

Terminations:

Medical Hx, Exposure Hx; Complete Physical Exam w/VS (BP, HR, RR, Temp); Labs: CBC, LFT, Lipid Panel, ALT, UA; PFT, Audiometric Test; ECG

Each 2

Return to Duty: Injury, Illness Driven Muscular-Skeletal, Extremities; Cardio-Vascular, Pulmonary Syst (ECG, PFT, CXR); Hearing – Audiometric Test; Visual Acuity, Color Vision;

Neurologic, Psychiatric Symptom Evaluation

Each 5

GRAND TOTAL CLIN 0001

OPTION 1 (CLIN 1001)

QUANTITY

UNIT

PRICE

TOTAL

COST

Pre-Placement: Med Hx; Comprehensive Med.Eval – HEENT (Audiogram; Visual acuity, color); Cardio-Pulmonary (ECG, PFT, CXR); GI & abdominal organs; Urinary, Reproductive Syst;

Spine, Axial skeleton, extremities; Neurological, Medical Hx, Exposure Hx Exam: HT, Wgt, BMI, VS (BP, HR, RR, Temp) HEENT, Neck, Cardio-Pulmonary, Abdominal Organs, GI, GU, Lymph Nodes, Skin, Hernia Ex, Labs: CBC, ALT, Lipid Panel, PFAS, Urine Dipstick; PFT, Audiometric Test, ECG; Visual Acuity, Color Perception, Confrontational Fields;

Each 54

Special Purpose Evals:

Cardio-Pulmonary (ECG, PFT, CXR); Skin Exam, HEENT – Vision, Audiometric test;

Musculoskeletal, Extremities; Neurologic. Lab:

HIV, Heavy Metals, UA/Micro-scopic;

Each 5

Terminations:

Medical Hx, Exposure Hx; Complete Physical Exam w/VS (BP, HR, RR, Temp); Labs: CBC, LFT, Lipid Panel, ALT, UA; PFT, Audiometric Test; ECG

Each 2

Return to Duty: Injury, Illness Driven Muscular-Skeletal, Extremities; Cardio-Vascular, Pulmonary Syst (ECG, PFT, CXR); Hearing – Audiometric Test; Visual Acuity, Color Vision;

Neurologic, Psychiatric Symptom Evaluation

GRAND TOTAL CLIN 1001

OPTION 2 (CLIN 2001)

QUANTITY

UNIT

PRICE

TOTAL

COST

Pre-Placement: Med Hx; Comprehensive Med.Eval – HEENT (Audiogram; Visual acuity, color); Cardio-Pulmonary (ECG, PFT, CXR); GI & abdominal organs; Urinary, Reproductive Syst;

Spine, Axial skeleton, extremities; Neurological, Medical Hx, Exposure Hx Exam: HT, Wgt, BMI, VS (BP, HR, RR, Temp) HEENT, Neck, Cardio-Pulmonary, Abdominal Organs, GI, GU, Lymph Nodes, Skin, Hernia Ex, Labs: CBC, ALT, Lipid Panel, PFAS, Urine Dipstick; PFT, Audiometric Test, ECG; Visual Acuity, Color Perception, Confrontational Fields;

Each 54

Special Purpose Evals:

Cardio-Pulmonary (ECG, PFT, CXR); Skin Exam, HEENT – Vision, Audiometric test;

Musculoskeletal, Extremities; Neurologic. Lab:

HIV, Heavy Metals, UA/Micro-scopic;

Each 5

Terminations:

Medical Hx, Exposure Hx; Complete Physical Exam w/VS (BP, HR, RR, Temp); Labs: CBC, LFT, Lipid Panel, ALT, UA; PFT, Audiometric Test; ECG

Each 2

Return to Duty: Injury, Illness Driven Muscular-Skeletal, Extremities; Cardio-Vascular, Pulmonary Syst (ECG, PFT, CXR); Hearing – Audiometric Test; Visual Acuity, Color Vision;

Neurologic, Psychiatric Symptom Evaluation

GRAND TOTAL CLIN 2001

OPTION 3 (CLIN 3001)

QUANTITY

UNIT

PRICE

TOTAL

COST

Pre-Placement: Med Hx; Comprehensive Med.Eval – HEENT (Audiogram; Visual acuity, color); Cardio-Pulmonary (ECG, PFT, CXR); GI & abdominal organs; Urinary, Reproductive Syst;

Spine, Axial skeleton, extremities; Neurological, Medical Hx, Exposure Hx Exam: HT, Wgt, BMI, VS (BP, HR, RR, Temp) HEENT, Neck, Cardio-Pulmonary, Abdominal Organs, GI, GU, Lymph Nodes, Skin, Hernia Ex, Labs: CBC, ALT, Lipid Panel, PFAS, Urine Dipstick; PFT, Audiometric Test, ECG; Visual Acuity, Color Perception, Confrontational Fields;

Each 54

Special Purpose Evals:

Cardio-Pulmonary (ECG, PFT, CXR); Skin Exam, HEENT – Vision, Audiometric test;

Musculoskeletal, Extremities; Neurologic. Lab:

HIV, Heavy Metals, UA/Micro-scopic;

Each 5

Terminations:

Medical Hx, Exposure Hx; Complete Physical Exam w/VS (BP, HR, RR, Temp); Labs: CBC, LFT, Lipid Panel, ALT, UA; PFT, Audiometric Test; ECG

Each 2

Return to Duty: Injury, Illness Driven Muscular-Skeletal, Extremities; Cardio-Vascular, Pulmonary Syst (ECG, PFT, CXR); Hearing – Audiometric Test; Visual Acuity, Color Vision;

Neurologic, Psychiatric Symptom Evaluation

GRAND TOTAL CLIN 3001

OPTION 4 (CLIN 4001)

QUANTITY

UNIT

PRICE

TOTAL

COST

Pre-Placement: Med Hx; Comprehensive Med.Eval – HEENT (Audiogram; Visual acuity, color); Cardio-Pulmonary (ECG, PFT, CXR); GI & abdominal organs; Urinary, Reproductive Syst;

Spine, Axial skeleton, extremities; Neurological, Medical Hx, Exposure Hx Exam: HT, Wgt, BMI, VS (BP, HR, RR, Temp) HEENT, Neck, Cardio-Pulmonary, Abdominal Organs, GI, GU, Lymph Nodes, Skin, Hernia Ex, Labs: CBC, ALT, Lipid Panel, PFAS,Urine Dipstick; PFT, Audiometric Test, ECG; Visual Acuity, Color Perception, Confrontational Fields;

Each 54

Special Purpose Evals:

Cardio-Pulmonary (ECG, PFT, CXR); Skin Exam, HEENT – Vision, Audiometric test;

Musculoskeletal, Extremities; Neurologic. Lab:

HIV, Heavy Metals, UA/Micro-scopic;

Each 5

Terminations:

Medical Hx, Exposure Hx; Complete Physical Exam w/VS (BP, HR, RR, Temp); Labs: CBC, LFT, Lipid Panel, ALT, UA; PFT, Audiometric Test; ECG

Each 2

Return to Duty: Injury, Illness Driven Muscular-Skeletal, Extremities; Cardio-Vascular, Pulmonary Syst (ECG, PFT, CXR); Hearing – Audiometric Test; Visual Acuity, Color Vision;

Neurologic, Psychiatric Symptom Evaluation

GRAND TOTAL CLIN 4001

APPENDIX B

LISTING OF FEDERAL HOLIDAYS

The following Federal Recognized Holidays are observed at March Air Reserve Base:

New Year’s Day 1 January Martin Luther King’s Birthday 3rd Monday in January President’s Birthday 3rd Monday in February Memorial Day Last Monday in May Juneteenth 19 June Independence Day 4 July Labor Day 1st Monday in September Columbus Day 2nd Monday in October Veterans Day 11 November Thanksgiving Day 4th Thursday in November Christmas Day 25 December

NOTE. When a Federal Holiday falls on a Saturday, the holiday will be observed the previous workday.

If the Federal Holiday falls on a Sunday, the holiday will be observed on the first workday following the Federal Holiday.