PWS T5 Firefighter Physicals.docx

Performance Work Statement (PWS) for

188th Air National Guard Pre-Employment & Annual Fire Fighter Physicals

1.0 General:

1.1 Scope: The objective of this Performance Work Statement (PWS) is to conduct and complete the requirements of physical examinations identified in NFPA (National Fire Protection Association) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.

1.2 Pre-Employment FF Physical IAW with the most current edition of the NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, Chapter 7.

1.3 Annual FF Physical IAW with the most current edition of the NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, Chapter 8.

1.4 PFAS Blood Testing (IAW DoD Manual 6055.05, Occupational Medical Examinations: Medical Surveillance and Medical Qualification), per occurrence.

1.5 The contracted entity shall be responsible to provide all materials, labor, supervision, equipment, and any incidentals necessary to provide the services detailed herein. No Government furnished equipment or property is to be provided.

1.6 The contracted entity will have to have the testing equipment for fit testing each firefighter for the MSA FireHawk M7 and the MSA G1 SCBA (Self-contained breathing apparatus).

2.0 Background: Air National Guard Fire Protection Activity (ANGFPA) Fire Fighters will comply with a pre-employment baseline physical examination identified in National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. Annual Physical/Medical Evaluation: ANGFPA Fire Fighters shall be medically evaluated periodically as specified in NFPA 1582.

3.0 Period of Performance (PoP): As specified in Master BPA

4.0 Schedule of Services: The contractor shall provide all services at a local Fort Smith, AR off-base facility, between 8:00 AM and 4:30 PM (AR time) Mon-Fri, except on recognized US holidays or when closed due to local or national emergencies. The vendor facility where services are to be provided, shall not exceed a distance greater than 30 minutes from the 188th Wing and must be within the Fort Smith Metropolitan Statistical Area. The 188th Wing is located at, 4850 Leigh Ave., Fort Smith, AR 72903.

4.1 Recognized Holidays: The contractor is not required to provide services on the recognized Federal Holidays. The following are recognized United States (US) holidays.

a. New Year’s Day

b. Martin Luther King, Jr.’s Birthday

c. Washington’s Birthday / President’s Day

d. Memorial Day

e. Juneteenth National Independence Day

f. Independence Day: July 4th

g. Labor Day

h. Columbus Day

i. Veteran’s Day

j. Thanksgiving Day

k. Christmas Day

4.2 Quality Control (QC): The contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s QCP is the means by which it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit 1, Performance Requirements Summary (PRS).

4.3 Quality Assurance (QA): The Government will evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government will do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and acceptable quality level(s) or defect rate(s).

4.4 Data Rights: The Government has unlimited rights to all documents/materials produced under this contract. All documents and materials, to include the source codes of any software, produced under this contract shall be Government owned and are the property of the Government with all rights and privileges of ownership/copyright belonging exclusively to the Government. These documents and materials may not be used or sold by the contractor without written permission from the KO. All materials supplied to the Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

4.5 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent OCIs, as defined in FAR Subpart 9.5. The contractor shall notify the KO immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the KO to avoid or mitigate any such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the KO. In the event the KO unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the KO may impose other remedies as he or she deems necessary, including prohibiting the contractor from participation in subsequent contracted requirements which may be affected by the OCI.

5.0 Requirements: The contractor shall:

5.1 The Contractor shall provide the 188th WG Air National Guard (ANG) Fire Chief or designee with a written Physician’s Medical Certification Pass/Fail Statement within two weeks (14 days) of the performing occupational physical, stating if employee is medically certified to safely perform the essential job tasks. Deliver hard copy with results within 30 days.

5.1.1 The report shall identify the presence of Category A or disqualifying Category B medical conditions in accordance with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, if present:

(1) Disqualifying Category B medical conditions in accordance with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments if present.

(2) The Contractor shall perform an occupational physical and provide 188th WG Air National Guard (ANG) Fire Chief or designee with Return-to-Work Medical Certification Statement for firefighters out of work for surgery or serious injury.

(3) The Contractor’s office shall be staffed with a physician that is a State of Arkansas licensed Doctor of Medicine or osteopathy, who has completed residency training in an accredited medical training program and/or is American Boards of Medical Specialties (ABMS), or American Osteopathic Association (AOA) board certified or international equivalent.

(4) The Contractor shall schedule appointments for occupational physicals and shall have a provider in attendance Monday through Friday between 8:00 AM and 4:30 PM (AR time).

(5) The Contractor shall schedule appointments, as requested by the department, within ten (10) business day.

(6) The Contractor shall have all necessary staff and equipment to perform all required services. Separate billing for outside services will not be accepted by the 188th WG ANG.

(7) Contractor shall forward copies of abnormal results along with patient instructions regarding primary care follow-up to firefighters with instructions to seek (as appropriate) medical follow-up to address any medical conditions, or lab abnormalities, identified during annual physical.

(8) If, during the physical exam, it is determined that the member needs to seek mental/behavioral health assistance, the contractor will have on staff or be able to refer member to a local mental/behavioral health specialist.

(9) Medical record keeping will be completed in accordance with NFPA 1582 and be subject to inspection by the 188th Air National Guard.

(10) Firefighter Physicals will follow NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments.

6.0 Medical record keeping and administration

6.1 All medical records including the identity, diagnosis, prognosis, or treatment of any patient or subject which are maintained in connection with the performance of any program or activity (including education, training, treatment, rehabilitation, or research) will be controlled under the requirements of 18 USC 3486(e), 18 USC 4247(e), 38 USC 5705, 38 USC 7332(a), 42 USC 242m(d), 42 USC 1320d-2(d)(2) and note(b)(Public Law 104-191 Section 264), 42 USC 15044(c), 42 USC 290dd-2(a), 29 CFR 1630.16(c)(3), 42 CFR 2.1(a), 42 CFR 2.2(a), 42 CFR 2.12(a), 42 CFR 2.13(c), 42 CFR 2.16(a), 42 CFR 2.21(b), 45 CFR 164.306(a), 45 CFR 164.502(a), and 45 CFR 164.508(a) authorities and marked appropriate as applicable.

6.1.1 All personnel information related to federal employees will be controlled under the requirements of 5 CFR 293.106 authorities.

6.1.2 All personally identifiable information related to military federal employees will be controlled under the requirements of 10 USC 130b(a), 10 USC 424(a), and 10 USC 1506(f) authorities.

6.1.3 All personally identifiable information, including sensitive personally identifiable information, related to federal employees will be controlled under the requirements of 5 CFR 297.401, 5 USC 552a(b), and OMB M-17-12 authorities. Privacy Act Statement will also be required for any information under this provision.

TECHNICAL EXHIBIT 1

Resources

Publication (Chapter/Page) Mandatory or Advisory Website

DoD 5200.48 Controlled Unclassified Information (CUI)

TECHNICAL EXHIBIT 2

Deliverables

Performance Requirements Summary (PRS)

This PRS includes performance objectives the Government will use to determine contractor performance and will compare contractor performance to the Acceptable Quality Level (AQL).

Standard Acceptable Quality Levels

(AQL)

Surveillance Method / By Whom

Deliver Firefighter Physical results no later than 14 days after the event.

Deliver hard copy with results within 30 days.

188th Fire Chief or designee

Inspection at

188th Fire Chief or designee with Return to Work Medical Certification Statement for 188th Air National firefighters out of work for surgery or serious injury.

completion of service/ 188th Fire Chief or designee

END PWS