RFQ-22-012-Radiology-PR.pdf

A. This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Federal Acquisition Regulation (FAR) Subpart 12.6, as supplemented with additional information included in this notice, FAR Part 12, Acquisition of Commercial Items (Title VIII of the Federal Acquisition Streamlining Act of 1994) (Public Law 103-355) & FAR 37.4, Non-Personal Health Care Services Contract (10 U.S.C. 2304 and 41 U.S.C 253). This announcement constitutes the only solicitation; proposals are being requested and a written solicitation will not be issued.

B. The Great Plains Area Indian Health Service (IHS) intends to award a Firm Fixed-Price, Non-Personal Healthcare

Service, Purchase Order in response to Request for Quote (RFQ) RFQ-22-012.

C. This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2021-07/2021-09-10.

D. This RFQ is an “Unrestricted” solicitation and the associated NAICS Code is 561320, which has a small business standard of $30.0.

E. The quoted unit pricing must be “all inclusive” (to include but not be limited to travel, lodging, per diem, fringe benefits, federal, state and local taxes) plus all other costs pertinent to the performance of this contract. Utilize your most competitive and reasonable rates.

Complete the attached Price Schedule.

1. CAT SCAN – 2080 Hours @ $__________ per hour x 3 months, totaling $__________.

2. Diagnostic Radiology Technician – 1040 Hours @ $__________ per hour x 3 months, totaling

3. Ultrasound Technologist – 1040 Hours @ $__________ per hour x 3 months, totaling $____________.

F. Provide Radiology Services (CT, X-Ray, and Ultrasound)

G. See attached Performance Work Statement. Services will be provided for the Pine Ridge Indian Health Service

Facility, 607 Indian Health Road, E. Hwy 18, Pine Ridge, South Dakota. The period of performance will be Date of Award through Three (3) months.

H. FAR 52.212-1 Instructions to Offerors-Commercial Items (September 2021).

Quotes shall be submitted on company letterhead stationery, signed, dated and it shall include:

1. Solicitation number RFQ-22-012;

2. Closing Date: November 26, 2021 at 12:00 pm CST;

3. Name, address and telephone number of company and email address of contact person;

4. Technical description of the item/service being offered in sufficient detail to evaluate compliance with the requirements of the solicitation. This may include product literature, or other documents, if necessary;

5. Price and any discount;

6. “Remit to” address, if different than mailing address;

7. A completed copy of the representations and certifications at FAR 52.212-3 (see FAR 52.212-3(b) for those representations and certifications that the offeror shall complete electronically);

8. Acknowledgment of Solicitation Amendments (if any issued);

9. Past performance information, when included as an evaluation factor, to include recent and relevant contracts for the same or similar items and other references (including contract numbers, points of contact with telephone numbers and other relevant information);

10. A statement specifying the extent of agreement with all terms, conditions, and provisions included in the solicitation. Offerors that fail to furnish required representations or information, or reject the terms and conditions of the solicitation may be excluded from consideration.

In addition, Contractors shall provide the following:

• Name and phone number of three (3) current professional references.

• Complete and sign Child Care Position/Personnel Security Office form.

• Complete and sign the Declaration for Federal Employment – Optional Form 306.

• Complete and sign Addendum to Declaration for Federal Employment (OF306).

• Complete and sign Licensure Requirement Form.

• Copy of malpractice insurance coverage.

• Shall meet the Qualifications and Knowledge Requirements in the Performance Work Statement and provide copies of the required documents (if needed).

• Copy of current Board Certification

• Copy of active, current, full and unrestricted license to practice.

• Copy of a recent Health Examination.

• Copy of Diplomas/Specialty Certifications.

• Copies of Continuing Education.

• Current CV/resume.

I. FAR 52.212-2 Evaluation – Commercial Items (October 2014) – See attachment for full text.

J. FAR 52.212-3 Offer Representations and Certifications-Commercial Items (February 2021). See attachment for full text. The Offeror shall complete only paragraph (b) of this provision if the Offeror has completed the annual representations and certification electronically via the System for Award Management (SAM) website accessed through http://www.acquisition.gov. If the Offeror has not completed the annual representations and certifications electronically, the Offeror shall complete only paragraphs (c) through (p) of this provision.

K. FAR 52.212-4 Contract Terms and Conditions-Commercial Items (October 2018). Applied to this acquisition and it’s incorporated by reference.

L. FAR 52.212-5 Contract Terms and Conditions Required to Implement Statutes or Executive Orders-

Commercial Items (September 2021). See attachment for full text.

M. Attached are the Federal Acquisition Regulations (FAR) & Health & Human Services Acquisition Regulation (HHSAR) clauses that are applicable including below.

N. Submit quote to:

Great Plains Area Indian Health Service Attn: Wenda Wright, Contract Specialist 115 4th Ave. SE, Room 309 Aberdeen, SD 57401 email wenda.wright@ihs.gov

Questions in regards to this solicitation shall be submitted in writing by either email no later than November 19, 2021, 12:00pm CST.

SECURITY CLEARANCE

A security pre-clearance must be performed for any employees referred to IHS through this contract.

Fingerprints must be completed and adjudicated prior to services being performed under this contract.

No contract award shall be made to any vendor or provider listed on the OIG Exclusion List http://exclusions.oig.hhs.gov throughout the duration of the contract. It shall be the responsibility of the contractor to notify the acquisition official if there is a change in provider.

Performance of this contract will require routine access by employees of the Contractor or its subcontractors to facilities or systems controlled by the Indian Health Service (I.H.S.). Before starting work requiring routine access to I.H.S.

http://www.acquisition.gov/ mailto:wenda.wright@ihs.gov http://exclusions.oig.hhs.gov/ facilities or systems each person must complete a FBI National Criminal History Check (Fingerprint Check) adjudicated by an I.H.S. employee using the Office of Personnel Management Personnel Investigations Processing System.

Contractors shall allow five business days for I.H.S. processing of fingerprints taken electronically at an I.H.S. site and thirty business days for non-electronic processing of fingerprints using FBI Form FD-258. A list of I.H.S. sites with electronic fingerprint capability is available from the Contracting Officer.

In addition, no Contractor or subcontractor employee shall be permitted to perform work under this contract if listed on the HHS Office of Inspector General List of Excluded Individuals/Entities (LEIE), http://exclusions.oig.hhs.gov. As soon as practicable prior to the start of work, the performance of the work the Contractor shall provide to the Contracting Officer the names of all individuals to be used in performance of work for screening against the LEIE. During the performance, the Contractor shall provide the Contracting Officer the names of any additional or substitute employees for screening before they begin work.

The Contractor is responsible for conducting security preclearance investigations in sufficient depth to ensure that each Contractor or subcontractor employee referred to I.H.S. is not on the LEIE and can obtain a favorable fingerprint clearance. Each security preclearance shall be conducted sufficiently in advance of the start of performance to avoid delays caused by denial of access. If this is a Time and Materials, Labor-Hour or Cost Reimbursement contract, the contractor shall not charge for or be reimbursed for labor hours or other costs incurred for employees who are unable to perform due to denial or access or the excess time required to resolve and clear unfavorable security clearance findings. If this is a Fixed Price contract, denial of access due to security clearance findings shall not be a basis for excusable delay or an increase to the contract amount.

Government will pay for the cost to process the contractors suitability clearances. However, multiple investigations for the same position may, at the Contracting Officers discretion, lead to reduction(s) in the contract price of no more than the cost of the extra investigation(s).

Employees that DO NOT have access to LMS, contractors, volunteers, or IHS employees with IPA’s or MOA’s to tribal organizations please, click here IHS Sexual Abuse Prevention website. When the contractors have completed and passed the training, please have them send a copy of the last page of the training with Name, Date, and Time to their Supervisor, COR, and Kimmen LeBeau, e-mail: Kimmen.LeBeau@ihs.gov

ACCEPTANCE PERIOD: Your proposal must stipulate that it is predicated upon all the terms and conditions of this RFQ. In addition, it must contain a statement to the effect that it is firm for a period of at least 30 days from the date of receipt by the Government.

“Radiology Technologist(s) will arrive on a Business Day ONLY to complete all Orientation and Background procedures.

The Clinical Director or Designee will ensure all Orientation and Background procedures have been completed and an email will be sent to the Contracting department to state as such. The Radiology Technologist(s) will NOT see patients until Background/Fingerprints have been cleared.”

“The standards of medical practice and duties of the Contractor through its Radiology Technologist(s) shall be determined pursuant to the bylaws of the Service Unit. The regulations of the hospital, applicable provisions of law, other rules and regulations of any and all governmental authorities relating to licensure and regulation of physicians and hospitals must be followed. Also the standards and recommendations of Centers for Medicare and Medicaid Services (CMS) or the Accreditation Organization must be adhered to. The Contract General Radiology Technologist(s) shall be required to participate in a quality improvement program, which is consistent with current requirements for ongoing monitoring and evaluation of the quality and appropriateness of care.”

A CONTINUING RESOLUTION, also known as a "CR" is legislation enacted by congress that continues funding for specific ongoing activities if the fiscal year appropriation has not been enacted by the beginning of the fiscal year.

"Due to the Continuing Resolution, funds are presently available through December 3, 2021 (P.L. 117-43). The Government's obligation for performance of this contract beyond that date is contingent upon the availability of appropriated funds. No legal liability on the part of the Government for any payment may arise for performance under https://www.ihs.gov/sexualabuseprevention/training/ mailto:Kimmen.LeBeau@ihs.gov this contract beyond December 3, 2021. If funds are made available to the Contracting Officer for performance beyond the above cited date, the Contractor will receive notification in writing by the Contracting Officer."

PRICE SCHEDULE

PINE RIDGE IHS HOSPITAL

Radiology (CT, X-Ray, and Ultrasound) Technologist(s) Services

BASE YEAR:

ITEM # DESCRIPTION ESTIMATED

QUANTITY

UNIT OF

ISSUE

UNIT COST TOTAL COST

1. CAT SCAN

Technologist

4 FTE Required 2080 Hours

2. Diagnostic Radiology Technician

2 FTE Required 1040 Hours

3. Ultrasound Technologist

2 FTE Required 1040 Hours

GRAND TOTAL FOR 90 Days: $ ___________

Total - 90 Days: $ _______________________

NON-PERSONAL SERVICE CONTRACT

RADIOLOGY DEPARTMENT

ULTRASOUND/ CT/ X-RAY TECHNOLOGIST(S)

THESE POSTIONS ARE LOCATED AT THE PUBLIC HEALTH SERVICE-INDIAN HEALTH

SERVICE, PHS INDIAN HOSPITAL, PINE RIDGE, S.D. 57770

PERFORMANCE WORK STATEMENT:

These positions serves as staffing for the radiology department with needs for (4) CAT Scan Technologist (CT), (2) General Diagnostic Radiology Technician (X-ray) and (2) Ultrasound Technologist and are responsible for performing complex radiologic examinations. Performs examinations and procedures, which are used in Medical diagnosis utilizing both stationary and mobile equipment. Operates the equipment in the radiology department and at patient’s bedsides. When there are no radiology exams to perform, the technicians will keep busy performing other departmental duties as assigned by the Radiology Supervisor.

NOTE***Vendor must provide radiation monitoring DOSIMETRY equipment to any candidates assigned to this contract.

MAJOR DUTIES AND RESPONSIBILITIES:

CAT SCAN TECHNOLOGIST – 4 FTE REQUIRED

Performs a variety of computerized tomography examinations according to physician instructions.

Receives and reviews requests from physicians and other health care providers for examinations of patients. Schedules patients for examinations. Determines the condition(s) at issue and the procedures and equipment necessary to best meet the needs of the individual case. Evaluates the nature of critical and emergency procedures and rearranges patient priorities to accommodate them. Confers with radiologists and/or higher graded tech. to establish requirements of nonstandard examinations or for cases outside of incumbent’s expertise, and determines technical factors, positioning, number and thickness of scans, etc., to satisfy requirements. Assists the radiologist in the performance of needle localizations and biopsies.

Receives and positions patient for examination. Explains procedures and actions to allay fears and secure maximum cooperation. Makes scans necessary for the requested examination. Advises radiologist or referring physician of results of examination and provides them with a preliminary diagnostic evaluation.

Notifies them of significant cases requiring their immediate attention and visualization while patient is undergoing examination. If unanticipated conditions or anomalies are discovered, extends and modifies procedure to insure full and accurate information as to findings and patient condition. If necessary, renders emergency aid and summons assistance.

Selects, sets up, adjusts, and operates equipment, including laser imager. Conducts examination, adjusting technique and equipment to best present the medically significant aspects found. Performs operator level maintenance and care of equipment. Identifies need for and initiates action to obtain higher-level support.

Makes minor adjustments to equipment. Performs preventative maintenance as required.

Establishes and maintains a variety of files and records relating to activities and functions. Prepares reports on examinations, equipment status and utilization, workload, supply status and consumption, and related matters.

Responsible for obtaining pertinent diagnostic examinations for the referring clinician and radiologist, requiring adequate and optimal positioning and recording of information on file.

Determines the number of scans necessary to obtain the information desired and adjusts the equipment parameters in such a way that a sufficient amount of information is obtained for each exam.

Recognizes the significance of all structures visualized on the screen at all times.

DIAGNOSTIC X-RAY TECHNICIAN: 2 FTE REQUIRED

Provide examination for all patients presenting to the Radiology Department after being examined by a Health Care Provider and exams ordered.

Independently operates a fixed and or portable radiology machine and equipment to meet the needs of the department.

Receives patients, explains methods of procedures, positions and sets technical factors to attain a high quality radiograph.

Performs a variety of routine to complex examinations to meet the needs of the Medical Staff, as well as, the needs of the specialty clinic physicians.

Performs DR (Konica- Minolta) duties to include creating image, performing QC on images on the screen to verify films, uses the digital processor and prepare the images for transmittal to PACS (SMAART) or Tele-radiology locations for Radiologist Interpretation and Final Report.

Prepares x-ray images for download to CD or electronic transmission for patient referral.

ULTRASOUND TECHNOLOGIST: 2 FTE REQUIRED

The Ultrasound technologist performs a variety of specialized technical procedures requiring independent judgements and initiative in the application of non-ionizing high frequency ultrasonic waves for disease diagnosis and obstetrical problems.

Performs all requested ultrasound studies dictated by the equipment available. Studies include, but are not limited to abdominal, pelvic and small parts.

Responsible for obtaining pertinent diagnostic examinations for the referring clinician and radiologist, requiring adequate and optimal positioning and recording of information on file.

Determines the number of scans necessary to obtain the information desired and adjusts the equipment parameters in such a way that a sufficient amount of information is obtained for each exam.

Recognizes the significance of all structures visualized on the screen at all times.

Capable of recognizing a diagnostic examination and interpreting it but not giving an official reading.

Receives patients, explains methods of procedures, positions and sets technical factors to attain a high quality sonography exams.

RESPONSIBLE DUTIES FOR ALL PERSONNEL IN THE RADIOLOGY

DEPARTMENT REGARDLESS OF SPECIALTY

Performs a variety of routine to complex examinations to meet the needs of the medical staff.

Independently operates a fixed and portable radiology equipment to meet the needs of the department.

Maintains accurate records of patient workload on a daily basis.

Keep accurate records of every sonography and radiology (CT or x-ray) exam, which has to be repeated.

Must be able to assist in a cardiac arrest situation and CPR along with the rest of the medical staff.

Must have their own personal dosimeter to read radiation doses as they are part of the radiology team and may have exposure due to departmental duties. The Pine Ridge Service Unit does not furnish dosimeter or Radiation safety badge to contractor staff.

WORK SCHEDULE:

Tour of duty will be rotating shifts Monday through Sunday days, evening and nights to include Holidays. The schedule will be arranged to benefit the IHS Pine Ridge Service Unit needs.

Occasionally the contractor may need to stay after shift to finish an exam or to do an emergency exam. Overtime pay will be approved at the regular hourly rate. The department will be covered on all 3 shifts as assigned and as determined by the Radiology Supervisor to meet patient workload. Shifts may be a variety of either 8 hour, 10 hour, 12 hour or 13.5 hours. The Radiology Supervisor or designee will communicate shift start times.

QUALIFICATIONS:

Individual must be :

Advanced-level certification by ARRT or NMTCB in CT or have one of the following qualifications :

• State Licensure that permits them to perform diagnostic CT and documented training in the provision of diagnostic CT or

• Registration and certification in Radiography by ARRT and documented training in the provision of diagnostic CT or

• Certification in Nuclear Medicine technology by ARRT or NMTCB And documented training in the provision of diagnostic CT

Must meet the continuing education requirement set by the ARRT for their specialty area.

1. CAT SCAN Tech must have at least six months of experience in performing CT examinations.

2. DIAGNOSTIC RADIOLOGY TECH must have 6 months experience in General Radiology and have current certification by ARRT or be registry eligible and documented proof of completion of an accredit radiology internship.

3. ULTRASOUND Tech must be ARDMS eligible and be experienced to perform a wide range of ultrasound. Must have at least one year of experience in performing ultrasound examinations.

Pine Ridge Indian Health Service hospital policy requires all staff with direct patient contact, be able to provide proof of PPD and Tdap (Tetanus, Diphtheria, acellular Pertussis). Influenza and COVID vaccination is a requirement as per Executive Order 14042. This includes all permanent employees, volunteers, and contractors (for all contractors in this category, acceptable proof can be in the form of an immunization record or written documentation from a physician).

Contractor personnel currently serving in a contract position can receive these immunizations from the facility.

KNOWLEDGE REQUIRED BY THE POSITION FOR CAT SCAN TECH:

Knowledge of physiology and cross sectional anatomy such as location, appearance and function of the various major and minor systems susceptible to radiological exposure and the physical abnormalities associated with most diseases or lesions to conduct computerized scanning examinations. In addition, knowledge of anatomy and physiology including location, appearance, and functioning of the major and minor systems susceptible to radiological illumination, and knowledge of changes to systems and organs caused by common medical and surgical diseases.

Ability to optimize scans for clarity for diagnostic use and to recognize when additional scans or different positioning is needed to fully illustrate exam area. Knowledge of complex radiographic exposure techniques such as determination of technical factors and machine geometry of linear tomographic X ray machines or equipment of similar complexity. Ability to perform calculations of critical technical factors needed to show the difference between organs, glands, etc. of similar density when contrast material cannot be used such as adapting for age, structure and patient size when performing mammographies, or use of contrast materials in invasive examinations. Knowledge of radiographic positioning required in complex procedures such as lumbar myelography including sequences of positioning, alignment of X ray beams and localizing of contrast medium. Skill to apply such knowledge to perform complex radiographic procedures such as bronchography, lymphangiography, or xerographic mammography. Ability to visualize the position and functioning of three-dimensional forms within the body from a two dimensional presentation (sonogram or cathode ray screen).

Skill in setting up, adjusting, operating, and maintaining diagnostic, tomography and ancillary equipment. In addition to the knowledge described above, a practical knowledge of instruments used in the specialization to make adaptations and adjustments and interpret test results based on previous experience and observation. This level requires a practical knowledge of intricate examination or treatment procedures. A basic knowledge of anatomy and physiology including location and function of the major body organs and structures as they relate to the specialization.

Knowledge of the common diseases and their effects associated with the specialization. Skill to apply knowledge in adapting instruments to perform a full range of specialized tests or nonroutine diagnostic or treatment procedures requiring many steps, and various approaches and procedures based on findings from the early steps. Knowledge of pharmacology and chemistry to understand drug action, effects, and method of administration. Ability to work as a member of a team when performing procedures that require making rapid and accurate observations or adjustments to established practices. Skill to prepare summary of test results, workload reports, and related documents.

1. Complete knowledge of complex instrumentation utilized to extract finest quality performance from the equipment.

2. Ability to deviate from normal techniques when necessary and to develop new and better techniques to keep diagnostic capability up to date.

3. Knowledge of radiation protection standards, devices, and techniques.

4. Knowledge of anatomy and physiology.

5. Knowledge of methods, techniques and quality control for digital imaging.

KNOWLEDGE REQUIRED BY THE POSITION FOR ULTRASOUND:

1. Knowledge and skill to operate complex ultrasound equipment to provide basis for a wide variety of specialized medical diagnosis. The knowledge and skill will have been obtained through formal classroom instruction of not less than 1 year.

2. Knowledge of physical diagnosis and clinical courses of disease.

3. Must be capable of recognizing a diagnostic scan and consulting with the radiologist to determine proper diagnosis.

4. Knowledge of physical principles of sound generation and transmission characteristics of the ultrasound equipment. Must be completely familiar with the following methods of signal processing: a. real-time scanning b. m-mode c. transducers

5. Complete knowledge of complex instrumentation utilized to extract finest quality performance from the equipment.

6. Ability to deviate from normal techniques when necessary and to develop new and better techniques to keep diagnostic capability up to date.

7. Knowledge of radiation protection standards, devices, and techniques.

8. Knowledge of anatomy and physiology.

9. Knowledge of methods, techniques and quality control for digital imaging.

SUPERVISION AND GUIDANCE RECEIVED:

Works under the supervision of the Chief Radiologic Technologist who advises on matters such as general operation of the Radiology section and patient relationships and occasionally spot checks sonographs and/or radiographs for diagnostic quality. When working on Ultrasound procedures, the Radiologist will indicate which actions should be performed. The technologist is responsible for the technical procedures to accomplish these directions. When working on CT or X-Ray procedures, the Radiologist will indicate which actions should be performed. The technologist is responsible for the technical procedures to accomplish these directions.

Radiologists provide guidelines initially, but textbooks, technical manuals, and current articles are available for additional guidelines in adapting the general requirements of the procedure to the specific condition of the patient.

Standard operating procedures cover the number, type and sequence of exposures for each kind of examination. Technique charts are available for typical settings of kilovoltage, milliamperage, distance and time for techniques. Textbooks and technical manuals on radiography are available for additional guidance in adapting the general requirements of the procedure to the specific condition of the patient. The technologist must use judgment to deviate from standard procedures and tables to compensate for patient’s injuries, illness, or physical disabilities in accordance with established precedent and methods of calculations. The technologist maintains up-to-date knowledge of new developments in the field and exercises judgment to evaluate their usefulness.

TECHNICAL EVALUATION FACTOR SELECTION WILL BE USED TO AWARD

SERVICE CONTRACT TO POTENTIAL VENDORS.

The summary is below and documentation forms for Contract Officer Representative monitoring processes will be attached to RFQ as well as the Technical Evaluation Tool for submission of proposal.

PROPOSAL EVALUATION SUMMARY:

CRITERIA

ADJECTIVAL RATING

ASSIGNED BY

REVIEWER

1. Submission of detailed work plan to meet the requirements in the statement of work

2. Past Performance and Experience

3. Key personnel are able to complete and be awarded background clearance status, comply with medical record documentation content and submission deadlines as outlined in Pine Ridge Service Unit By-laws, conforms with Center for Medicare Service accreditation regulations or Joint Commission regulations, and participate in quality of care project management. (Quality Assurance Surveillance Plan)

FINAL RATING

QUALITY ASSURANCE PLAN SURVEILLANCE

QUALITY OF CARE

The Contractor shall comply with the following quality of care protocol:

1. It shall be understood that eligible patients under treatment will be rendered services that provide the best medical care within the Contractor's professional training and experience. All services rendered shall be in accordance with current standard medical practices to assure quality of care. A 30-day Work Schedule will be provided to the contractor by the Radiology supervisor prior to the dates needed.

2. The Contractor shall be familiar and adhere to the policy and procedures of Radiology

Department at the Pine Ridge Service Unit in South Dakota. The education and training (i.e the credentials) of the Contractor shall comply with the Medical Staff By-laws of the service unit for all services provided in Public Health Service clinics and the Statement of work requirements for this position. The Contractor shall agree to abide by the HIPAA and CMS standards.

3. The quality of work performed by the Contractor will be subject to review by chart audits, review by the Radiology Supervisor, Radiologist, and site visits by the Contract Officer Technical Representative, Vendor Project Officer or designee as needed. The Radiology Supervisor and/or Radiologist will conduct quality Review audits.

The Contractor shall comply with the following quality of care protocol:

1. Deliverable 1: The Vendor will provide Curriculum Vitale and education documentation for candidates presented to fulfill the requirements of this contract. The PRSU will review the Vendor for all background clearance actions for compliance. (See attachment 2a)

2. Deliverable 2: The Vendor for the Ultrasound/Sonographer/CAT SCAN/ X-Ray Radiology Technician contract will provide documentation of current education and training, and will also support and participate in the ongoing Continuous Quality/ Performance Improvement at the Pine Ridge Service Unit. Quality Assurance: The Program will consist of reporting the. (Quality Activity 2e)

3. Deliverable 2: The Vendor will ensure timely completion of documentation of RPMS/ PACS (electronic health record and digital radiologic program). Radiology Supervisor will accuracy prior to signing timecards at the end of each week. If malicious discrepancies are identified, vendor will ensure timely correction of documentation and or replacement of candidate. Vendor will work with Radiology Supervisor to ensure quality care is provided. (See attachment 2b)

4. Deliverable 3 conducted by the Government: Compliance with CMS and/or JC accreditation surveys. PRSU will be conducting Environment of Care rounds, Internal Audits, Tracer activities, etc. Any deficiencies cited that involve contractor staff, will be addressed for correction with the Department Supervisor and Vendor as necessary. (See attachment 2c)

PERSONAL CONTACTS AND PURPOSE OF CONTACTS:

Personal contacts are with patients, with doctors, and with fellow employees in a hospital setting.

These contacts are for the purpose of making radiology (CT or X-ray) and Sonography studies.

Contacts with doctors are to resolve problems concerning scheduling of patients and requested procedures. Those with fellow workers are to establish a working relationship to accomplish the job. Contacts with patients are to explain the procedure to be performed, often to patients who are unfamiliar with radiology examinations and to direct patients how to move to achieve correct positioning. Some patients are ill, injured or nervous which requires the technologist to provide reassurance and comfort.

PHYSICAL DEMANDS AND WORK ENVIRONMENT:

The work requires long periods of standing and walking. There is some bending and carrying of moderately heavy DR panels and other supplies as needed. It is often necessary to physically lift patient(s) from gurneys to x-ray table with assistance from others. The work area is well lighted and temperature controlled. Special safety precautions are used to reduce exposure to radiation.

These include using minimum exposure settings for the x-ray machine and never operating the machine except from behind a protective screen or when wearing protective clothing such as a lead apron.

NOTE***The contract vendor will provide the radiation dosimeter badge for their employee

QUALITY ASSURANCE:

In working with the Chief Technologist who is functioning in assuring work is satisfactory, work will be thoroughly monitored and approved. After approval, payment shall be invoiced to Great Plains Area Office – Pine Ridge Service Unit for payment. Along with this invoice, shall be a record of time worked, signed by departmental supervisor or designee.

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Indian Health Service Office of Human Resources

Memorandum

To:

From:

Subject:

Date:

Supervisor of child care covered position incumbent Human Resources/Personnel Security Office Child Care Position Provisional Authorization

This is notice you will supervise a position that is covered by Public Laws (P.L.) 101-630, Indian Child Protection and Family Violence Prevention Act and 101-647, Crime Control Act. The Indian Health Service is required to compile a list of all authorized positions with duties and responsibilities that Involve regular contact with or control over Indian children and investigate the character of each individual who is employed or is being considered for employment in such a position. The requirement is that the individual is to be under the supervision and in sight (chaperoned) of a previously investigated staff person (favorably adjudicated).

The position and individual identified below has been designated as a covered position and has been granted provisional authorization:

Name:

Position title:

The following criteria must be met for the above mentioned individual:

► Pre-employment suitability has been favorably adjudicated prior to entrance on duty.

► Continue with processing of background investigation - Tier 1 with child care (minimum).

► Provide requested documentation/information as requested from the Personnel Security/HR

Office.

Employee/Contractor/Affiliate must be 100¾ chaperoned at all times by a staff person and/or alternates who have at a minimum a favorably adjudicated Tier 1 with child care (Tier 1 C) or CNACI investigation.

The following individuals listed below agree and accept responsibility of the chaperone role.

Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated Chaperone name: ___________ Case type favorably adjudicated

I have verified a favorable investigation is on file for identified chaperones:

Personnel Security/HR Office designee Date

Your signature indicates you are accepting responsibility, will comply with the above criteria, and will assure the above named individual will be chaperoned at times while on site.

Department Supervisor/Designee Date

This provisional authorization is in effect until the favorably adjudicated certification of investigation is in place. I am aware that failure to comply with the above criteria could result in removal and termination of the granted provisional authorization.

Employee/Contractor/Affiliate Date

Declaration for Federal Employment"'

('Thia form may also be used to eases& fltneu ror federal contract employment) form Al)prove<l:

0MB No 3206-01$2

Instructions-------------------------------

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Privacy Act Statement

The Office of Personnel Management Is authOrlzed to request this Information under sections 1302, 3301, 3304, 3328, and 8716 or title 6, U.S. Code. Sectlon 1104 of tllle 5 allows the Office ot Personnel Management 10 delegate personnel management functions to other Federal agencies. If necessary, and usually In conjunction with another form or forms, this form may be used In conducting an Investigation to determine your sultablllty or your ability to hold a security clearance, and II may be disclosed to authorized offlclels making similar, subsequent determinations.

Your Social Security Number (SSN) Is needed to keep our records accurate, because other people may have the same name and birth dale. Public Law 104-134 (Apr/I 26, 1996) asks Federal agencies to use this number to help Identify Individuals In agency records. Giving us your SSN or any other Information Is voluntary. However, If you do not give us your SSN or any other Information requested, we cannot process your appllcellon. Incomplete addresses end ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure or this record or Information In this record Is In accordance with routine uses found In System Netice OPM/GOVT-1, General Personnel Record�. This system allows disclosure of Information to: training faollllles; organizations deciding claims for retirement. Insurance. unemployment, or health benefits; officials In lillgatlon or administrative proceedings where the Government Is a party; law enforcement agencies concerning e vlolntlon or law or regulallon; Federal agencies for stallslical reports and studies: oHicials of labor organizations recognized by law In connection with representation of employees; Federal agencies or olher sources requesting Information for Federal agencies In connecllon with t'llrlng or ratalnlng, security clearance.

securlly or sullablilty lnvostiga!ions, classifying Jobs, contructing, or Issuing licenses. grants, or olher banellls; public and private organizations, Including news media, which grant or publicize employee recognitions and awards; the Maril Systems Protection Ooard, the Office of Special Counsel, the Equal EfTlployment Opportunity Commission. the Federal Labor Rolellons Authority, Iha National Archives and Records Adtninlstretlon, end Congressional offices In connection with their officla.l functions; prospective non-Federal employers concerning tenure of employment, clvU service status, length of service, end lhe date ond noture of action for separation as shown on the sr- 50 (or authorized exception) of a specifically Identified Individual: requesting organizations or Individuals concerning the home address and other relevant information on those w110 mlgM have contracted en Illness or been exposed to a health hazord; authorized Federal and non-Federi:il agencies for use In computer matching: spouses or dependent children asking whether the employee has changed from a sell-and•famlly to a sell-only hea!th benents enrollment; lndlvldueh;

working on a contract, service, grant, cooperative agreemenl. or job for the Federal government; non-agency members of en agency's performance or other panel; and agency-appointed representaHves or employees concerning Information Issued to the en1ployees about fitness-for-duty or agency-flied dlsablllty rellroment procedures.

Publlc Burden Statement ----------------------------•

Public burden reporting for this collecllon of Information Is estimated lo vary rrom 5 to 30 minutes with an average of 15 minutes per response, Including time for reviewing 1nstn1c1lons, searching existing data sources. gathering the data needed, and complellng and reviewing the collectlon of information. Send comments regarding the burden esllmete or any olher aspect of the collection of Information, Including suggestions for reducing lhls burden, to lhe U.S. Office of Personnel Management, Reports and Forms Manager (3206-0102), Washington, DC 20415-7900. The 0MB nurnber, 3206-0102, Is valid. OPM may (101 coltec;t this Information, and you are not required lo respond, unless this number Is displayed, U.S. Office of Personnel Management 6 U 9 C 1302, 3301, 3�, 3328 & 8718

�form"°6 R•vl>ed Ociober 2011

Provk>u■ edllk>n1 0010/ole and unuub/o

Declaration for Federal Employment* ("This form may also be used to 11&eeu mne88 for federal contraot employment)

GENERAL INFORMATION

fom, /.pproved:

0MB No. �206--0182

1. FULL NAME (Provide your full name. If you h11ve only Initials in your name, provide them and Indicate "Initial only". If you do not have I middle name Indicate "No Middle Name", If you ara a "Jr.," "Sr.," etc. enter this under Suffi>1, First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER

3b, ARE YOU A U.S. CITIZEN?

3a. PLACE OF BIRTH (Include city and state or country)

J YES I. NO (lf"NO", provide country of citizenship) ♦

4, DATE OF BIRTH (MM/0D/YYYY)

6, OTHER NAMES EYER USEC (For example, maiden name, nickname, elo) 6, PHONE NUMBERS (Include area codes)

Selective Service Registration

Doy ♦

Night ♦

If you are a male born after December 31, 1959, and are at least 1 B years or age, civil service employment law (5 U,S,C, 3326) requires that you must register with the Selective Service System, unless you meet certain exemptions, 7a. Are you a male born after December 31, 1959? ,:; YES r/ NO (If "NO", proceed to 8.)

7b. Have you registered With the Selective Service System? 1: YES (lf"YES", proceed to 8.) r: NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) In Item 16.

MIiitary Service 6, Have you ever served In the United States military? L,, YES (If "YES", provide tnronmetlon below) 1· NO

If you answorod "YES,• I/st the branch, dates, and type of dlschafTJfl for all active duty.

If )'our oll/)1 active duty was trlllnlng In the Reserves or Notional Guard, answer "NO,"

Branch From (MM/D0/YYYY) To IMM/00/YVYY) Type of Discharge

Background Information

For ell quoetlone, provide all additional requeetod Information under ltom 16 or on attachod eheots. The clrcumsIonce.s of eoch event you list wlll be considered. However, In most cases you can sllll be considered for Federal jobs.

for questions 9, 10, and 11, your answers should Include corwte1lons resultlng from a plea of nolo contondere (no contest}, but omll (1) lrllfOu fines of $300 or less, (2) any vlolallon of law commlllod befote your 16th birthday, (3) aoy violation of law committed before your 10th blnhdey Jr nnalty decided In fuvonlle court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or slmilar slate law, and (6) any convicllon for which the record was expunged under Federal or state law •

o. During the lest 7 years, have you been convicted, been Imprisoned, boon on probation, or been on parole? r· YES /! NO (Includes felonies, nreorrns or explosives vlolotlons, mlsdomoenors, and an other offenses.} If "YES,• use ffem 16 to provi<ltJ tho <Joto, exp/anal/or, of tllo vlo/11/ion, ploco of occurronca. anct Illa nomo and addross of tho police department or court Involved.

1 o. Have you been convicted by a mlllta,y cou,1-martlal In the pest 7 years? (If no m/11/ary service, answer "NO.") If "YES,• usu //1:1111 1 (J 10 pro Ide /he data, 01<plonatlon of I/lo violo//on. p/11c nf nccurronoo, end Iha name and address of tho mllitary authority or courl lnvo/Vod,

11. Aro you currently undor charges for any vlototlon or 1ow? If "YES," 11so /tom 16 to provide tho date, oxplonof/on of fho v/olol/on, ploco of occe1rroni;e, end the name and uddross of the po/loo doparlmont or court /11volvod.

12. During the lost 6 years, heve you been fired from any fob for an>' reason, did you quit alter being told that you would be fired, did you leevti any job by mutual agr-eement because of specific problems, or were you debarred (rom federal employment by tho Office of Personnel Menegomenl or any other Federal agency? If "YES,'' use I/om 16 to provide tho da/o, an oxplonallon of the prob/om, reason for /uovlng, end f/Ju employers name and oddmss.

13. Are you delinquent on eny Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of bonents, end other debts to the U.S. Government, plus dofavlts of Federally guaranteed or Insured loans such os student end homo mortgage loans.) If "YES," use !tam f6 to provfdo tho typo, lonr,th, and amount ofthe t10ll111wo11cy or dRfou/1, and stops /hat you ora taking lo correct 1/IO error or ropoy /ho dobt.

r n

Yl;S I. NO

YES ,1 NO

YES ,, NO

YES I NO

U.S. Office of Personnel Management 6 U 6 C 1302, 3301, 3»!, 3328 a. 8715

Op10,01f FCl<ffl X,O ROYllod QclObtl 2011 f'1ovtov1 edMon.t «,1olet1 ind Ur'IJHbla

Declaration for Federal Employment* ('Thia lorm mey also be ueed to aHeU fitness for re de rel contract employment, Additional Questions fom, /.jlptOYod:

0MB No, 320e-0l82

14. Do any of your relalivas work for the agency or government organization 10 which you are submitting th/a form?

r(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, . YES I NO father-In-law.mother-In-law, son-In-law, daughter-In-law, brother-In-law, sister-In-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, and hall sister.) If "YES,• use flam 16 to provide the re/a/Ive"s name, relationship, and the department, agency, or branch of the Armed Forces for which your ro/atlve worns.

15, Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay baaed on mllltary, 1 YES r NO Federal civilian, or District of Columbia Government service?

Continuation Space/ Agency Optional Questions ------------------- 1e, Provide details requested In Items 7 through 15 and 18c In the space below or on attached sheets. Be sure to Identify attached sheets with your name, Social Security Number, and item number, and to Include ZIP Codes In all addresses, If eny questions are printed below, please answer as Instructed (these questions are speo/fio to your position and your agency Is authorized to ask them).

Certifications I Additional Questions

APPLICANT: If you are apply Ing for a position and have not yet been ■elected, carefully review your answers on this form and any attached sheets, When !his form and all attached materials are accurate, read Item 17, and complete 17a.

APPOINTEE: If you are being oppolntod, carefully review your answers on this form and any attached sheels, Including any other appllcatlon materlols that your agency has attached to this form. If any information requires correction to be occurate as of the date you are signing, make changes on this form or lhe ahachmenls andfor provide updated Information on addlUonal sheets, lnltlrillng and dating ell changes and additions.

When this form and all attached materials ere accurate, read Item 17, C-Ompleta 17b, read 1 B, end answer 18a, 18b, and 10c as appropriate.

17. I certify that. 10 lho best or my knowledge end belier, all of the lnrormetlon on and elteched to this Declaratlon for Federal Employment, Including any aUached applicaHon materials, la true, correct, complete, and made In good faith. I undel"ltand that a falao or fraudulenl answer to any question or item on any part of this declaration or Its attachmonts may bo grounds for not hiring mo, or for firing me after I bogln work, and may be punishable by fine or lmprleonment. I understand thal any Information I give may be investloated for purposes of determining ellglbl\lly for Federal employment as allowed by law or Presldenlle\ ardor. I consent to the release of Information about rny ability and lilness for Federal employment by employers, schools, law enforcement agencies, and other lndlvlduels and oroanlzalione 10 lnvestlga10,s, personnel sµeclalist&, end other authorized employees or representallves of the Federal Govemmenl. I understand that for financial or lending \nstilutions, medlcal Institutions, hospitals, health care professtonals, and some other sourcos of Information, a separate spec!t1c release may be needed, and I mey be contacted for such e release al a late, date.

Appointing Offic11r:

17a. Applicant's Signature: .,,,.,.-----------------

(Sign In Ink) Date ______ _ En111 0'1• or ,lj>polnl/nonl 01 Corwt11lon

17b, Appointee's Signature:�---,�,-,--------------- (Sign In Ink)

Date _____ _

MMIDDIYYYY

18. Appolntoe (Only respond It you have boon employed by the Federal Government before); Your eleellons of life Insurance during previous Federal employment may effecl your ollg\blllly for life Insurance during your new appointment. These questions are asked to help your personnel office.make a correct determination.

18a. \!Vhan did you leave your last Federal Job?

MM/00/YYYY

DATE:

16b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life Insurance?

I, YES

1 Be, If you answered "YES" to Item 18b, did you later cancel the waiver(s)? If your answer lo Item r: YES 16c Is "NO," use Item 16 to Identify the type(s) of Insurance for which waivers were not ··· canceled.

U.S. Office of Personnel Management 6 U s,c, 1302, 3301, 3»4, 3320 "8710 r NO I DO NOT KNOW

I NO I DONOTKNOW

OpOorelF<>rm30I!

Rovlltd O<M>er 2011

Pr11vlou11dlllon1 ob1olat1 and um11l>l1

0MB Approved Form No. 0917-0028 Expiration Date: 2/28/2022

Addendum to Declaration for Federal Employment (OF 306)

Indian Health Service

Child Care & Indian Child Care Worker Positions

Item 16. Agency Specific Questions

Name: ____________ _ Social Security Number: _______ _ (Please print)

Job Title in Announcement: Announcement Number:

Section 231 of the Crime Control Act of 1990, Public Law (Pub. L.) 101-647, requires employment applications for individuals seeking employment in…