PWS Template.pdf

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Performance Work Statement V1.0 [Effort][Version][Date]

5.0 Requirements

The medical qualification components of the firefighter examination determine the likelihood of a firefighter’s ability to safely execute the essential functions of the job.

Command and supervisory personnel, in consultation with HR personnel in the case of DoD civilian employees, identify medical qualification standards and physical requirements for duty positions within the context of associated environmental factors. For DoD civilian employees, medical qualification standards must be established by DoD or DoD Components in compliance with OPM requirements in Section 339.205 of Title 5, CFR, and Equal Employment Opportunity Commission requirements in Part 1630 of Title 29, CFR.

The examining OM provider serves as an advisor to the command, supervisory, and HR personnel and does not create medical standards or physical or position requirements or make employment decisions.

The examining OM provider determines medical qualifications and notifies command, supervisory, and HR personnel, as applicable, who take into account the examining OM provider’s determination, in making the decision of suitability for a position or function.

In accordance with the requirements of the office of personnel management (OPM) for specific job codes and data obtained from IH surveys, screening is required for employees exposed to potential health hazards in the workplace. OPM provides medical qualification standards for Fire Protection and Prevention positions at https://www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards/0000/fire-protection-and-prevention-series-0081.

The MDANG is seeking a fee for Occupational Health services to conduct required candidate preplacement and member OH examinations.

Testing requirements for the medical screening and surveillance examinations are as follows but not limited to: (cost by line item must be provided)

Chest x-ray (CXR)- Frequency: Baseline, 5 years, Termination Screening 12 lead EKG - Frequency: Baseline, As Indicated Respirator Questionnaire – Frequency: Baseline, As Needed.

Occupational Spirometry- Frequency: Baseline, Annual and Termination Pulmonary Functions Test (PFT) Frequency: Baseline, Annual and Termination Hearing and Audiogram- Frequency: Baseline, Annual and Termination

Lab work Fasting blood sugar - Frequency: Baseline, Annual and as indicated-: Repeat the test on subsequent day, if result falls outside of normal or expected range. A repeat result found outside of normal or expected range should prompt a request for additional information.

Urinalysis- Frequency: Baseline, Annual and Termination Check pH, specific gravity, protein, glucose, ketones, blood, RBCs, and white blood cells

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HIV Antibody- Frequency: Baseline, As Needed Tetanus and diphtheria vaccines- Frequency: Baseline, Annual and Termination Hepatitis B Antibody/ Vaccine and titers- Frequency: Baseline, As Needed Hepatitis A Antibody/ vaccine- Frequency: Baseline, As Needed Hepatitis C Antibody- Frequency: Baseline, Annual and Termination Complete Blood Count with differentials (CBC w/diff) Frequency: Baseline, Annual and Termination Comprehensive Metabolic Panel (CMP)-Frequency: Baseline, Annual and Termination Measles Titer- Frequency: Baseline, Annual and Termination Mumps Titer- Frequency: Baseline, Annual and Termination Rubella Titer- Frequency: Baseline, Annual and Termination Varicella Titer- Frequency: Baseline, Annual and Termination T-SPOT- Frequency: Baseline, Annual and Termination Lipid Panel- Frequency: Baseline, Annual and Termination Heavy Metals- Frequency: Baseline, Annual and Termination Blood Zinc Protoporphyrin (ZPP)- Frequency: Baseline, Annual and Termination Blood Lead (BL)- Frequency: Baseline, Annual and Termination Blood Cadmium (CdB) blood- Frequency: Baseline, Annual and Termination Urine Cadmium (CdU)- Frequency: Baseline, Annual and Termination Urine Chromium- Frequency: Baseline, Annual and Termination Urine (UA) Dipstick- Frequency: Baseline, Annual and Termination Urine Arsenic- Frequency: Baseline, Annual and Termination B2 Microglobulin- Frequency: Baseline, Annual and Termination PSA (Males Only)- Frequency: Baseline, Annual and Termination Medical History - Frequency: Baseline, Annual and Termination

Specifically Evaluate:

Disorder, condition, diagnosis, or symptom: - Of sudden or subtle incapacitation. - That may impact the ability to perform position-specific essential functions. -Impacting night vision, visual acuity, visual fields, and depth perception, including the use of contacts other than for refractive errors; assess for current or recurrent diplopia.

Prescription and over-the-counter medication use, including vitamins and supplements.

Difficulty distinguishing basic colors (e.g., no history of difficulty distinguishing between reds, greens, browns and oranges, blue and purple, blue and yellow, violet and red, or blue and green).

Level of physical activity. Participation in sports activities may be a good indicator of cardiovascular and pulmonary fitness.

Cardiovascular, peripheral vascular, pulmonary; or metabolic disorder diagnosis, medical condition, or symptom.

Psychiatric or psychological diagnosis, condition, or symptom; medical diagnosis or condition that adversely impacts behavior.

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Interview with employee to discuss available results and questionnaires and annotate notes in medical records.

Exam/Vital Signs – Frequency: Baseline, Annual and Termination

Specifically Evaluate:

Temperature, blood pressure, pulse. • Repeat the blood pressure on a subsequent day, if result falls outside of normal or expected range. A repeat result found outside normal or expected range that would lead to medical disqualification should prompt a discussion to inform the examinee that they may provide additional information.

Head and general body appearance and form: Evaluate for body configuration, deformity, contractions, or spasms that could interfere with or prevent satisfactory performance of job functions, including the inability to wear PPE (e.g., body armor), as required by the position.

Ears, nose, throat, oral cavity, including teeth and gums.

Neck: Specifically evaluate range of motion (deficit could adversely impact targeting use of weapon), thyroid, presence of carotid bruits.

Heart, lungs, thorax, abdomen Thorax: Heart sounds, lung auscultation. Abdomen: Liver size and tenderness, ventral hernia, inguinal hernia.

Skin: Specifically note peripheral vascular skin perfusion.

Eyes and surrounding tissues: • Specifically examine eyelids, conjunctiva, cornea, and surrounding tissues. Evaluate for condition affecting function sufficient to interfere with vision or impair protection of the eye from exposures. • Visual field testing by confrontation.

Visual acuity testing with and without corrective lenses, if used. Ability to distinguish basic colors tested using pseudo isochromatic plates or other accepted objective tool(s). • Fundoscopic evaluation to visualize blood vessels and assess peripheral vasculature for changes or abnormalities

Neuromuscular: Evaluate deep tendon reflexes, balance, and motor steadiness and strength of upper and lower extremities, including hand and foot. For those positions requiring the use of a weapon, both the dominant and nondominant hands should have sufficient strength, control, and coordination to maintain possession of the duty issued weapon and to take possession of an adversary’s weapon during a confrontation.

Ability to verbally communicate, including the ability to articulate understandably. Observe interaction during office visit.

Emotional and mental stability: Observe behavior and interaction during office visit.

Review mental health history and evaluate for signs of emotional or mental instability during the interview and the mini-mental status examination (e.g., the Teng Mini-Mental State Examination available at https://healthabc.nia.nih.gov/sites/default/files/mmse_0. pdf).a

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Workplace Exposure Summary - Frequency: Baseline, Annual and Termination

Polyfluoroalkyl Substances (PFAS) - Frequency: Baseline, Annual and Termination

While required by law to offer testing, participation is voluntary.

Section 707 of Public Law 116-92 requires DoD to offer blood testing to all DoD firefighters for exposure to per- and polyfluoroalkyl substances (PFAS) during their annual physical examination. PFAS testing is not part of firefighter medical surveillance or qualification, but is done solely to assess exposure. This requirement is only to offer blood (serum) testing for select PFAS compounds and record the testing results of the concentration of PFAS in the firefighter’s OH record. Current scientific evidence does not indicate that blood levels will identify a health problem, predict or rule out the development of future health effects, or provide information for medical treatment. Medical surveillance procedures detailed elsewhere in this issuance do not apply.

The PFAS compounds specified in this paragraph will be tested.

(1) Perfluorooctanoic acid.

(2) Perfluorooctanesulfonic acid.

(3) Perfluoronanoic acid.

(4) Perfluorohexanesulfonic acid.

(5) Perfluorobutanesulfonic acid.

(6) Perfluoroheptanoic acid.

These PFAS compounds were selected for the DoD firefighting testing panel because they:

(1) Have been associated with aqueous film-forming foam used by DoD firefighters.

(2) Are part of the larger testing panel of the National Health and Nutrition Examination Survey of the general public.

Test results that are received after the service date will be reviewed by a Board-Certified Occupational Health Physician (BCOHP) and provided to MDANG Occupational Health Nurse (OHN) with relevant recommendations.

The services requested are for testing, screening and evaluation purposes therefore medical treatment is not required or authorized. In the event additional testing is required for a suspected occupational related issue consult with the contracting officer’s representative (COR) prior to conducting.

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Contractor will consult with the COR on health concerns involving employees that may arise during operations or upon receipt of results that are not readily available on site (i.e. lab results).

The privacy of the employee must be ensured at all times.

Test Panels. Testing will occur based on the requirements of the job code/job title and known or suspected exposures. The list of testing requirements for each employee will be provided by MDANG OH to the contracted agency.

Contractor will provide a by name list of employees seen and test performed prior to departing the work site.

If abnormal findings are identified, the contractor shall notify the employee and the MDANG OH immediately to be referred accordingly.

Fitness for Duty (FFD)-IAW DoD 6055.5-M (determining whether an employee is medically and physically able to perform the assigned duties without substantial risk of harm to themselves, others, or the mission), and OSHA CFR 1910.120 for clearance to wear a respirator. Documentation at a minimum, the agency medical officer completes Part D of the OF-178, or its equivalent DoD Component medical qualification form, for the appropriate employment category of the applicant or examinee, indicating either:

(a) Medically qualified or that the examinee has been medically qualified if restrictions are accommodated. Specify restrictions and, if known, include expected restriction duration; or

(b) Medically disqualified, with an explanation. Explanations should not mention specific medical findings unless they are obvious without an examination.

Examples of explanations are:

1. The examinee is monocular, and job requires binocular vision.

2. Severe hypertension or uncontrolled diabetes could be reported as: “Existence of a condition associated with incapacitation,” without mentioning blood pressure or diabetes.

The completed Part D of the OF-178 or equivalent DoD Component medical qualification examination documentation is returned to the authorized requesting official.

Personnel files and medical information will only be sent to and discussed with the individual and MDANG OH.

Contractor will arrange for initial coordination of services with the designated COR within fifteen (15) working days after award of the contract. Instructions and required paperwork for employees will be forwarded to: Maryland Air National Guard Occupational Health Office, [Effort][Version][Date]

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Attn: Occupational Health Nurse, 2701 Eastern Bld. Baltimore MD 21220 and received no later than 15 days prior to start date of service.

Protected Health Information (PHI). The contractor shall not release any medical or personal information of an employee without first receiving written approval from the individual. The COR will provide the regulations upon request by the contractor IAW FAR 52.212-4, Privacy of Protected Health Information (DEC 2002) [Health Information Portability and Accountability Act (HIPAA)].

Protection of Personally Identifiable Information (PII). The contractor shall protect all PII encountered in the performance of services IAW Defense Federal Acquisition Regulation Supplement (d) 224.103 and DoDD 5400.11, Department of Defense Privacy Program, and DoD 5400.11-R. If a PII breach results from the contractor’s violation of the aforementioned policies, the contractor shall bear all notification costs, call-center support costs, and credit monitoring service costs for all individuals who’s PII has been compromised. Protection of Personally Identifiable Information training is available through this link and must be completed within fifteen (15) days of service start date for staff:

https://securityawareness.usalearning.gov/piiv2/index.htm.