SitevisitRFP0215156.doc

VENDOR

SITE VISIT EVALUATION FORM

Revised 05/15/2009

Reviewer’s Name: ___________________________________________________

Field Office: __________________ RA: _______________________________

Assigned Regional Occupational Health Nurse Consultant: ___________________

Date of Visit: _____________________ Annual Visit: ____

PO # ______________

PreAward RFP # ________________________

Name of Vendor: ___________________________________________________

Address of Vendor: __________________________________________________

Telephone Number: __________________________________________________

Contact Names and Numbers:

Medical Director: ____________________________________________________

Administration: ______________________________________________________

Scheduling Coordinator: _______________________________________________

Billing: _____________________________________________________________

Location of Office within 15 miles of FO – RA served? Reference RFP, F.10 Y N Comments:

I

PROGRAM OBJECTIVES - SCOPE OF WORK

A. Provide a complete health examination of Special Agent Applicants, Special Agents (SAs), other specialized applicants, and employees of the FBI in order to enable the determination of fitness for duty, ability to perform essential job functions including, but not limited to strenuous physical exertion, world-wide deployment and any defects which would restrict or prohibit participation in defensive tactics and dangerous assignments which might entail the practical use of firearms.

B. Provide Occupational Health Services to FBI Field

Office locations as specified by the Contracting Officer Technical Representative (COTR), to include emergency response, immunizations, venipuncture, health education and medical consultations.

C. Having a quality assurance plan in place for all services provided.

· Is the vendor’s scope of work in compliance with services requested in Statement of Work (SOW)?

· Do operational processes for physical examinations, diagnostic testing and counseling meet expectations of the SOW?

· What is the plan for appointment schedule of FBI work

· What is the current policy for drop in medical care at that facility?

· Please address any deficiencies in space below, include which, if any elements of the scope of work can not be accomplished by this vendor. If there are any sub contractors please list names and locations.

· Evidence of malpractice insurance reference RFP, H.12.h

II VENDOR WORK ENVIRONMENT

1. Work Conditions in compliance with the SOW? Reference OSHA regulations, SOW section C. 18.0, 21

· Cleanliness Y N Comments:

· Temperature Y N Comments:

· Lighting Y N Comments:

· Space Y N Comments:

2. Blood borne pathogen program? Reference OSHA regulations, SOW, section C

Y N Comments:

3. Bio-hazardous Waste disposal regulations? Reference OSHA regulations, SOW, section C Y N Comments:

4. Quality improvement/assurance program Reference RFP, section E.8 page 31 Policy and procedure manuals for staff

Y N Comments:

· Secure storage of FBI employees personal belongings Reference C.18

Y N

· Weapons storage Reference C.18

· Storage of FBI employees medical records reference C.19, H.1a-g

Y N Comments:

· Annual HIPPA training when HCPU database is implemented. Reference RFP, H.12

· Computer Security: Reference RFP, H.12.1.2 a-r

Y N Comments:

· Vendor has ability for use of our software? Reference RFP, section C.20

Y N

· Microprocessing audiogram on site? Y ___ N ____

III TEST AND PROCEDURES

· Visual observation of the following equipment is required: Reference RFP, C.21, E.4

· EKG: Preventive Maintenance (PM) Sticker present – date_______

Y N

Comments:

· Audiology Testing

· Hearing Booth PM Sticker present - date_____ Y N

· Audiometer PM Sticker present - date _________ Y N

· Logs up to date? Y N Comments:

· Vision Testing:

· Color vision Y N

· Visual Acuity Y N

· FAA visual requirements Y N Comments:

· Exercise Stress Testing

· Treadmill PM Sticker present – date_______

Comments:

· Monitoring System PM Sticker present – date ___________

Comments:

· Pulmonary Function Equipment PM Sticker Y N Date ________

· Log Books Y N

· Calibration up to date Y N

· Other Testing on site or off site:

If off site provide name of testing facility & ensure vendor has billing agreement with sub contractors

· Immunizations Reference RFP,C.j and F.6 CDC and Public Health guidelines

· Check refrigerator to include temperature reading logs as applicable

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