Solicitation - W81K0026QA057 Certified Trauma Registrar.pdf

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SEE CONTINUATION

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W81K0026QA057 09 JAN 2026

BOBBY ETHERIDGE

254-288-4769

22 JAN 2026

10:00 AM

W81K00 100

W40M MRC0 WEST

MEDICAL READINESS CONTR OFFICE WEST, 3160 MCINDOE BLDG1103

JBSA FT SAM HOUSTON, TX 78234-4504

UNITED STATES

BOBBY ETHERIDGE, EMAIL: BOBBY.J.ETHERIDGE.CIV@HEALTH.MIL

TELEPHONE: 254-288-4769

561110

USD 12,500,000.00

SEE CONTINUATION

W81K0026QA057

Statement of Equivalent Rates for Federal Hires (May 2014)

In compliance with the Service Contract Labor Standards statute and the regulations of the Secretary of Labor ( ), this clause identifies the classes of service employees 29 CFR Part 4 expected to be employed under the contract and states the wages and fringe benefits payable to each if they were employed by the contracting agency subject to the provisions of 5 U.S.C.5341 or 5 332.

This Statement is for Information Only: It is not a Wage Determination

Certified Trauma Registrar

GS7

(End of clause)

(w) The non-FAR Part 12 discretionary FAR and DFARS clauses included herein are incorporated into this contract either by reference or in full text. If incorporated by reference, see clause 52.252-2 herein for locations where full text can be found.

(End of Addendum)

*** END OF NARRATIVE 1 ***

Department of Defense

Defense Health Agency

Performance Work Statement

Service: Certified Specialist in Trauma Registries (CSTR)

Location: Carl R. Darnall Army Medical Center, Fort Hood, Texas

Date: 2/1/2026

PART 1

PERFORMANCE WORK STATEMENT

1.2. The service specifies are as follows: Trauma Registrar, 1 Full Description of Services:

Time Employee (FTE), Deputy Commander Inpatient Services (DCIS).

1.5. General Information:

Non-Personal Services: The following labor categories are under a non-personal services arrangement.

It is expressly agreed and understood that this contract is a non-personal services contract, as defined in Federal Acquisition Regulation (FAR) 37.101, under which the professional services rendered by Contract Personnel (CP) are rendered in their capacity as independent Contractor or personnel of any independent company that may be a party to this contract. The Government may evaluate the quality of professional and administrative services provided but retains no control over the professional aspects of the services rendered. The Contractor shall be solely liable for and expressly agree to indemnify the Government with respect to any liability producing acts or omissions by its personnel or agents. This contract does not create an employer-employee relationship between the Government and any corporation, partnership, business association or other party or legal entity with which the individual CP may be associated. CP providing the services are not subject, either by the contract terms or by the manner of its administration, to the supervision and control usually prevailing in relationship between the Government and its employees.

1.5.4. Quality Assurance: The Government will evaluate the Contractor's performance under this contract IAW a separate Quality Assurance Surveillance Plan (QASP). This Government-only plan is primarily focused on what the Government will do to ensure that the Contractor has performed IAW contract performance standards. The Contract QASP provides a systematic method to evaluate performance to include how the performance standards will be applied, the frequency of surveillance, and the acceptable quality levels for each of the metrics identified in Exhibit 1, Performance Requirements Summary. The QASP is created with the premise that the Contractor is responsible for management and quality control actions to meet the terms of the contract while the Government is responsible for quality assurance actions.

1.5.5. Government Representative (GOVT REP): The following individual is designated as the Government Representative for this contract:

Government Representative: D'Anita Byrd

Government Representative Email Address: danita.m.byrd2.civ@health.mil

Government Representative Telephone Number: (254)-553-3799

1.5.6. Recognized Holidays: Contract CSTRs will will not be required to work on federally recognized holidays:

New Year's Day, January 1st

Martin Luther King's Birthday, 3rd Monday in January

President's Day, 3rd Monday in February

Memorial Day, Last Monday in May

Juneteenth Day, June 19th

Independence Day, July 4th

Labor Day, 1st Monday in September, Columbus Day, 2nd Monday in October

Veteran's Day, November 11th

Thanksgiving Day, 4th Thursday in November

Christmas Day, December 25th

1.5.7.1. Hours of Performance: The performance hours of the MTF are as follows:

7:00 am - 4:00 pm Monday through Friday w/1-hr lunch

7:30 am - 4:30 pm Monday through Friday w/1-hr lunch

8:00 am - 5:00 pm Monday through Friday w/1-hr lunch

1.5.7.2. Scheduling: The schedule or scheduling process is as follows:

Duty hours shall be as set forth by the applicable Department Chief or his/her designated Duty hours shall be asset forth by the applicable Department Chief or his/her designated Government representative. The Contractor shall provide services for a 40 hours/week or 80-hours/pay period. The Contractor shall provide services for work weeks averaging 40 work hours consisting of five (5) eight (8)-hour work shifts scheduled Monday thru Friday between the hours of 7:00 a.m. and 5:00 p.m. The Department Chief or his/her designated person will schedule shifts. A minimum one (1)-hour unpaid meal break provided during the shift (as determined by the department) which is not paid by the Government. The Government reserves the right to review all of the hours worked by the Contractor personnel by any means necessary, to include but not limited contract: requiring the use of a time clock, scanning the CSTR's CAC in a timeclock, checking computer log-in log-out times, using a sign-in sheet, checking with MTF staff or other methods deemed appropriate. The Contractor shall invoice only for actual hours worked. Hours scheduled for shifts do not include travel involved in reaching the MTF or work site.

Overtime hours may be authorized with prior approval. Overtime is defined as hours worked in excess of 40 hours per week due to critical mission needs.

The Contract CSTR shall be rested and fully physically and mentally capable for performing the duties required under this contract.

Unpaid meal breaks (lunch) are mandatory daily.

CSTRs cannot work through unpaid meal break to accommodate late arrival or early departure as that is considered unauthorized compensatory time.

There is no set time for unpaid meal breaks and times may change daily; however, the unpaid meal break must be taken within the scheduled shift. Unauthorized working through unpaid meal breaks are not billable.

A Government representative will release CSTRS for unpaid meal breaks.

Government representatives may at times be involved in extreme demanding and busy situations therefore CSTRs have a responsibility to approach Government representative if it is realized an unpaid meal break has not been provided so one can be afforded.

Clocking in prior to scheduled times will not be considered as hours worked.

Staying late past scheduled times will not be considered as hours worked unless requested by the Government and approved due to the Government's mission. Hours worked in excess of 40 hours per week, is considered overtime.

Signing in prior to schedule or stay late past scheduled time to complete mandatory training is not authorized. All training must be done during normal duty hours.

The contract CSTRS shall not leave the hospital during designated shift hours (excluding meal breaks) or without prior coordination with the Clinical Supervisor. Time away is not considered actual hours worked.

Completing contract vendor requirements while on Government time is not authorized and not considered actual hours worked.

Additional shifts may be added or changed with the agreement of the Contractor and the Government Representative to include less than eight (8) hours per shift Sunday through Saturday, including nights, weekends, and/or holidays.

Hours worked do not include travel time to reach the Military Treatment Facility (MTF) or other place of performance.

1.5.7.3. Recording CSTR Time: Changes to the recording of CSTR time identified in the contract PWS are as follows: None.

1.5.7.4.3. CSTRs and Substitutes: If the Contractor substitutes permanent CSTRs for a temporary period of time, the substitute shall meet the same qualification standards and health requirements as stated in the contract and TO. Substitutions will be required when the permanent CSTR is unavailable for more than thirty calendar days. Additional qualification and standards are as follows:

Knowledge of medical terminology

Certificate for completion of a trauma-specific ICD-10 course every 5 years

Proof of completion of the Abbreviated Injury Scale (AIS) course

Certificate from a trauma registry course offered through the American Trauma Society (ATS)

Certification as a Certified Specialist in Trauma Registries (CSTR)

Certification as a Certified Abbreviated Injury Scale Specialist (CAISS)

Maintains a minimum of 24 hours of trauma-related continuing education (CE) per survey cycle

1.5.7.5 Closures: During a planned closure of the facility due to training, holiday or unplanned closure due to unusual and compelling circumstances (e.g., natural disasters, military emergencies, severe weather), the Contractor will:

be compensated only for the actual hours the CSTR provided services be compensated for the unplanned closure (personal services only)

1.5.7.5.1 Unplanned Closures: Other than the federal holidays listed in paragraph 1.5.6, the following are considered training days or days where the CSTR will not be required to work on this contract: N/A

1.5.8. Place of Performance: The work to be performed under this contract will be at Carl R.

Darnall Army Medical Center, Fort Hood, Texas.

1.5.9. Mission Essential: The following labor categories are designated as mission essential:

None.

1.6.1. Quality Control Plan (QCP): The Contractor shall have a planned and systematic QCP that outlines the quality control process covering every aspect of the Contractor's operation under this contract. The Contractor shall submit a Contract QCP to the Government

Representative as outlined in Exhibit 2 of this contract. The GOVT REP will approve the QCP in writing. The Contractor shall submit changes to an approved QCP to the GOVT REP for approval throughout the life of the contract.

1.6.3. Periodic Progress Meetings: Contractor will will not be required to attend periodic progress meetings at no additional cost to the Government. The terms at which the periodic meeting will be conducted include: N/A

1.6.4.1. Contractor Representative: The Contractor shall submit the Contractor representative contact information and any other key personnel, in writing, to the GOVT REP.

1.6.4.2. Representative Status Change: The Contractor shall notify the GOVT REP in writing of changes in the status (i.e., termination or replacement) of designated Contractor representative within two business days of the change.

1.6.6. Contractor Travel: Reimbursement will will not be provided for travel within a 40-mile radius of the place of performance. CSTR travel requirements are as follows:

1.6.7. Relocation Costs: The Government will will not pay the Contractor to relocate CSTRs.

1.6.9 Orientation: Orientation will be paid at the billable rate or compensated separately.

1.6.9.2. Computer Skill Competency: Each CSTR shall demonstrate competency as required in the contract and as follows:

Position requires access to Department of Defense computer systems, therefore CSTRs shall be a U.S. Citizen or otherwise meet the requirements of AR 25-2 and any electronic record systems CSTRs may be required to utilize in the performance of assigned duties.

Shall be able to type and have had experience using computers especially Microsoft programs.

CRDAMC will provide computer training for the CRDAMC computer system.

Shall be able to read, write, and speak English well enough to effectively communicate with patients, staff, and other healthcare providers.

1.6.10. MTF Training: Additional training requirements are as follows:

Computer Training. Contract contractor employee who have any interaction with the MTF computer systems must receive training for the applicable system. All Contractor staff that access Government IT systems shall be trained in security awareness, protection of Government sensitive and privacy information, and their responsibility and consequences before access is authorized. The Government Representative or appropriate Government designee will coordinate computer training. The training will be on-site and during normal duty hours. This training will be at no cost to the Contractor. Training is not reimbursable to the Contractor if completed off-site.

The Government may elect to provide unique Government training to contract personnel who are performing services under this contract. If the Government elects to provide such training, the Government will provide such training at no additional expense to the Contractor or to the contract personnel. When directed by the contracting officer, contract personnel shall attend all such training in a paid status as part of the normal services required and billed under the contract. If determined by the contracting officer, such training may require a performance commitment by the Contractor and the Contractor shall reimburse the Government (by means of a reduction in an invoice) if a contract personnel fails to satisfy the performance commitment after the contract personnel receives the unique Government training.

1.6.12. MTF Standards: Specific policies, procedures, and instructions/regulations for the place of performance are as follows:

All services shall be provided in accordance with established standards, principles and ethics of the profession and applicable professional specialty organizations, The Joint Commission (TJC) standards, applicable Department of Defense(DoD) and service specific regulations, directives and policies, as well as MTF policies, procedures and job descriptions. Contract CSTRs shall give the highest regard to patient dignity and observe the precepts of the American Hospital Association's Bill of Rights for Patients. Contract CSTRs shall provide services in conjunction with other non-contract providers to include physicians, nurse practitioners, physician assistants, registered/licensed practical nurses and support personnel. All contract CSTRs shall perform essentially the same functions, within the scope of acceptable practice, as those required by Army or Government service health care professionals of similar experience and in similar duty assignments.

1.6.20 CSTR Health Requirements: The Contractor shall shall not provide documentation certifying health requirements such as immunizations, annual vaccinations, medical testing (i.e., tuberculosis, N95 particulate respirator duckbill mask fitting) and physical examination when required at the time of initial placement.

1.6.20.3. Occupational Health: The CSTR shall shall not be required to obtain documentation of required physical testing or a report of a physical examination.

MMR vaccine - 3 doses or Rubella, Rubeola and Mumps igG titers showing positive results (if needed, must be taken no less than two (2) weeks prior to report date)

PPD (TB skin test) - 2 tests within the past 12 months or a QFT Gold showing negative results within the past 12 months. A copy of a chest x-ray if you have a history of a positive TB test

Varivax vaccine (chickenpox) - 2 doses or Varicella igG titer showing positive results Influenza vaccine (flu shot) - annually

Hepatitis B vaccine - 3 doses or HBsAB showing positive results. Current BCLS, PALS, etc.

cards (health care providers only)

1.6.20.5. Tuberculosis Screening: The additional immunization/screening requirements for the risk of exposure to tuberculosis (TB) are as follows:

Tdap vaccine within the last ten (10) years

1.6.25 Competency-Based CSTR Interviews: Prior to CSTR placement, the Government will will not contact the CSTR to determine if the CSTR meets the requirements set in the contract and/or contract.

PART 3

GOVERNMENT FURNISHED PROPERTY, EQUIPMENT, AND SERVICES

3. Government Furnished Items and Services:

3.1. General: The following additions are made to the Government furnished items and services for this contract:

The Government will provide use of all available MTF facilities and support services, materials, publications and forms, and equipment required for contract performance (except as designated in the contract).

Contract personnel shall keep Government furnished supplies, equipment, and work areas in a safe, orderly and clean condition. Contract personnel shall notify the Government of any damage, stolen, broken furnished supplies and equipment.

Emergency Contract Personnel Healthcare. The MTF will provide Emergency healthcare for injuries occurring while on duty. The Contractor shall reimburse the Government for such services.

The Government will provide an MTF identification badge and a Common Access Card (CAC).

While performing work under this contract, he/she shall wear a Government-furnished, visible identification badge on the front of the outer clothing. Contractor personnel must comply with MTF policy regarding the badges and identification cards.

Any space used by contract personnel in performance of this contract may be used for other purposes during their absence. Items of clothing, personal effects, or equipment may not be able to be secured at all locations. The Government will not incur any liability for theft, damage to, or loss of such personal items.

Personal Protective Equipment (PPE). Contract personnel shall wear special protective clothing and shoe covers, when required, which shall be supplied by MTF. In all cases, the Contractor shall conform to the established personal appearance policy of the MTF as well as IAW MEDCEN Regulation 670-1, Uniforms, Civilian Dress, and Military Courtesy.

3.2. Government Computer Access Requirements: eneral: The following additions are made to the Government furnished items and services for this contract:

This contract requires contractor personnel to have access to government computers, contractor personnel requiring access to government computers shall successfully complete, Tier 1 (T1) formerly known as National Agency Check with written Inquires (NACI) (equivalent or higher) background investigation before obtaining access to the computer. These investigations shall be submitted by the government at no additional cost to the contractor.

Common Access Cards (CACs) for Contractor Personnel are required which is hereby incorporated by reference if not otherwise included. The contractor shall comply with Homeland Security Policy Directive

(HSPD)-12, Army Directive 2014-05 "Policy and Implementation Procedures for Common Access Card Credentialing and Installation Access for Uncleared Contractors", Policy for Common Identification Standard for Federal Employees and Contractors and Federal Information Processing Standard 201.

Standard Contract Language and Instructions for Remote Connectivity by Virtual Private Network:

General Government Oversight Instructions

Program/Project Managers will follow the policies and procedures identified in the contract language.

Specifically, Program/Project Managers will ensure that Standard Contract Language and Instructions for All Government Data Including Protected Health Information is included in all contracts that require a VPN connection.

Business Partners that require access to government systems will follow Army Regulation 25-1, "Army Knowledge Management and Information Technology, AR 25-2, "Information Assurance (IA)", DoD Health Information Privacy Regulation.

Business Partner Responsibilities

Use the MEDCOM Business to Business Virtual Private Network Gateway or the Military Health Systems Virtual Private Network Gateway as the only approved access solutions.

Initiate, maintain, and document personnel security investigations appropriate to the Business Associate Representative's responsibilities and required access to MEDCOM Sensitive Information (SI) as determined by the site Chief Information Officer.

Validate that systems authenticate users through the use of the Common Access Card (CAC) or CAC alternative as a part of a two-factor authentication mechanism on the business partner side of the VPN.

Provide, maintain and configure VPN concentrator that complies with DoD security standards.

Ensure Government Property, if utilized is maintained and returned in the same condition to Site.

Site Responsibilities

Provide Business Partner with the appropriate level of security requirements for the type of access requested and ensure that the Business Partner remains compliant.

Provide Business Partner with Government Property or contractor furnished equipment which meets two factor authentication requirements to access the government network, not to include the VPN concentrator.

Ensure return of Government Property utilized by Business Partner.

PART 4

CONTRACTOR FURNISHED ITEMS AND SERVICES

4. Contractor Furnished Items and Responsibilities: None.

PART 5

PERFORMANCE REQUIREMENTS

Labor Category: Specialized Medical Support- Trauma Registrar

CSTR Qualifications:

5.1. The CSTR must have obtained certification through the American Trauma Society and have been at least one year of working as a Certified Specialist in Trauma Registries (CSTR) performing the following duties: Abstraction, Coding, Data Entry, and Quality Improvement Audits. Certified Specialist in Trauma Registries (CSTRs) are data information experts that capture a complete history, diagnosis, treatment, and health status for every eligible trauma patient according to program and regulatory requirements and guidelines. They ensure appropriate trauma patients are captured, assure accurate documentation of procedures and diagnosis, and other pertinent data necessary. All verified trauma facilities are required to provide trauma data to State, regional and national registries.

In addition, Carl R. Darnall Army Medical Center (CRDAMC) is a verified Level 3 Trauma Center established by the American College of Surgeons (ACoS) Committee on Trauma, therefore, CRDAMC is required to adhere to the ACS Trauma Standards which include uniform coding as specified according to National Trauma Data Bank and Trauma Quality Improvement Program standards). This data provides essential information to researchers, healthcare providers, and public health officials to better monitor, treat and prevent trauma. CSTR's work with physicians, administrators, researchers and health care planners to provide support for trauma program development, ensure compliance of reporting standards, and serve as a valuable resource for trauma information with the ultimate goal of preventing and controlling traumatic injuries.

5.2. CSTRs abstract a wide range of medical data from the EMR and code it in compliance with data standards. CSTRs must maintain a thorough understanding of anatomy and physiology, medical terminology, surgical procedures, as well as ICD-10 coding guidelines to inpatient diagnoses and procedures.

5.3. All coding is correlated from supporting clinical documentation in the medical records.

CSTRs independently research and solve complex coding problems and assist with special projects as required. CSTRs also ensure adherence to data management protocols as set forth in state and national requirements, departmental standards, perform other related duties incidental to the work described herein.

5.4. The Contractor shall ensure that all CSTR providing services under this contract shall be able to read, write, and speak English well enough to effectively communicate with all parties and other health care providers. In addition, if the position requires the use of computers, the contract personnel shall be computer literate.

5.5. The CSTR shall possess sufficient initiative, interpersonal relationship skills and social sensitivity such that he/she can relate constructively to a variety of patients from diverse backgrounds.

5.6. The CSTR shall have the required education, training, experience and documented current competence in the required specialty position description. CSTR must maintain an adequate number of continuing education credits to maintain certification.

5.7. The purpose of this contract is to support the CRDAMC Trauma Program in the maintenance of the trauma registry. Contract CSTR's will identify areas for coding /documentation improvement in all areas to enhance data quality and minimize patient risk, conduct workload accuracy audits ensuring compliance, facilitate coding timeliness and accuracy. They will prepare submissions to supervisor on coding and audit activities pending or complete Contract CSTR assists with the preparation of, and participation in, the trauma program verification survey/prepares reports for the trauma service. Contract CSTR will interface with other areas of the hospital and outside organizations to obtain the proper information needed to accomplish tasks (i.e., information management for computer support or questions, physicians to clarify patient care issues,. They will perform and ensure uniform and consistent coding and reporting of all diagnoses according to program and regulatory requirements and guidelines. Contract CSTR will ensure proper sequencing of injuries, assures accurate documentation of procedures, and provides sufficient text documentation to support the National Trauma Data Standards (NTDS), Trauma Quality Improvement Program (TQIP), State and Regional registries and any local requirements. They will perform and ensure uniform and consistent coding and reporting of all required registry data to he National Trauma Data Standards (NTDS), Trauma Quality Improvement Program (TQIP), State and Regional registries and any local requirements within the timeframe as required by the respective entity and industry standards.

5.8. Legal Authorization to Work in the United States: CSTRs performing under this contract must be a U.S. Citizen.

5.9. Qualifying Package: The Contractor shall provide a complete, current, and accurate qualifying package for the background check, and certification verification.

5.10. Security Investigative Requirements: The estimated average time, in days, it takes to complete a security investigative package on this contract is: 60-120 days. The Contractor shall ensure CSTRs comply with the following security requirements not already identified in the contract PWS:

Must provide to Government Representative

Copy of Resume (resume must include day, month, and year of experience)

Complete PSI Form 748-1

Complete OF306

Complete Texas Consent and Authorization to Retain Fingerprints

DD2681

DD3150

Submit copy of birth certificate and SSN Card

Submit copy of change of name documents (if last name different than birth certificate)

Additional requirement may be needed at the discretion of the Security Officer

5.11. The CSTR shall complete either a SF-85 or an SF-86 Questionnaire for National Security Positions (or equivalent OPM investigative product)

5.12. Malpractice Insurance for Non-Personal Services: The Contractor and all subcontractors shall shall not meet the requirements of FAR Clause 52.2377, Indemnification and Medical Liability Insurance, for its CSTRs, in the following amounts for the entire performance period of the CONTRACT: N/A

5.13. Schedule Management: The TO will establish the work schedule and billable hours for each CSTR. The Contractor shall maintain a process to monitor work and billable hours on the contract. When directed by the Government, the CSTR shall remain on duty to complete patient treatment where lack of continuity of care would otherwise jeopardize patient health. This provision is not intended to apply to the time required to complete routine tasks (e.g., completion of paperwork or routine administrative tasks at the end of a shift) which are to be completed as part of the normal work schedule.

5.14. Excess Hours: Excess hours are often used by the Contract to pay overtime pay to their contractor employees.

5.15. Billing for Services: The Contractor will only be paid for the actual hours the CSTR provides services.

5.16. Task 6 - Reports. The minimum level of metrics maintained at the Contract level include CSTR overall fill rate, turnover rate, and replenish rate. Acceptable Quality Levels (AQLs) on these metrics are set in Part 8 Exhibit 1, PRS in this contract. The minimum values for AQLs on Contract metrics are set as follows:

Overall Fill Rate: > 90%

On-Time Fill Percentage: > 90%

Turnover Rate: < 20%

Replenish Rate: > 90%

The minimum level of metrics will be calculated as follows:

5.17.1.1. Overall Fill Rate: The overall fill rate is the percentage of the total amount of required FTE-weighted days (i.e., purchased) filled in a reporting period. The overall fill rate is calculated by dividing the sum of FTE-weighted days CSTRs fill a position in a reporting period by the total number of required FTE-weighted days in the same reporting period.

5.17.1.2. On-Time Fill Percentage: Percentage of FTEs filled by the required start date during the reporting period. The on-time fill percentage is calculated by dividing the number of initial and replacement FTEs assigned with a required start date in a reporting period filled on time by the total number of initial and replacement FTEs assigned with a required start date in the same reporting period.

5.17.1.3. Turnover Rate: The number of FTEs that turned over during a reporting period. The turnover rate is calculated by dividing the number of assigned FTEs turned over in a reporting period (for any reason unless the GOVT REP informs the PMO not to count the turnover) by the total number of assigned FTEs in the same reporting period. Turnovers occurring less than 30 calendar days before the end of the contract will not be counted as a turnover for this metric.

5.17.1.4. Replenish Rate: The replenish rate is a measure of how well assigned positions remain filled in a reporting period. The replenish rate is calculated by dividing the sum of FTE-weighted assigned CSTR days in a reporting period by the sum of FTE-weighted days available subsequent to initial CSTR assignment start dates in the same reporting period.

5.17.1.5. Additional Metrics: Additional metrics, to include customer satisfaction, complaint resolution percentage or local metric, on this Contract are are not identified in Exhibit 1, PRS.

PART 6

OTHER TERMS, CONDITIONS, AND PROVISIONS

6.4.4. Health Insurance Portability and Accountability Act (HIPAA): Additional or supplemental instructions unique to HIPAA for this TO are as follows:

6.4.4.1. AT Level I training. This standard language is for contractor employees with an area of performance within an Army controlled installation, facility or area. All contractor employees, to include subcontractor employees, requiring access Army installations, facilities and controlled access areas shall complete AT Level I Awareness training within calendar days after contract start date or effective date of incorporation of this requirement into the contract, whichever is applicable. The contractor shall submit certificates of completion for each affected contractor employee and subcontractor employee, to the Government Representative or to the contracting officer, if a Government Representataive is not assigned, within calendar days after completion of training by all contractor employees and subcontractor personnel. AT level I Awareness training is available at the following website: http://jko.jten.mil.

6.4.4.2. Access and general protection/security policy and procedures. This standard language is for contractor employees with an area of performance within Army controlled installation, facility, or area. Contractor and all associated subcontractor employees shall provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services or Security Office. Contractor workforce must comply with all personal identity verification requirements (FAR clause 52.2049, Personal Identity Verification of Contractor Personnel) as directed by DOD, HQDA and/or local policy. In addition to the changes otherwise authorized by the changes clause of this contract, should the Force Protection Condition (FPCON) at any individual facility or installation change, the Government may require changes in contractor security matters or processes.

6.4.4.3. For contractors requiring Common Access Card (CAC). Before CAC issuance, the contractor employee requires, at a minimum, a favorably adjudicated National Agency Check with Inquiries (NACI) or an equivalent or higher investigation in accordance with Army Directive 201405. The contractor employee will be issued a CAC only if duties involve one of the following: (1) Both physical access to a DoD facility and access, via logon, to DoD networks onsite or remotely; (2) remote access, via logon, to a DoD network using DoD approved remote access procedures; or (3) physical access to multiple DoD facilities or multiple non DoD federally controlled facilities on behalf of the DoD on a recurring basis for a period of 6 months or more. At the discretion of the sponsoring activity, an initial CAC may be issued based on a favorable review of the FBI fingerprint check and a successfully scheduled NACI at the Office of Personnel Management.

6.4.4.3b. For contractors that do not require CAC, but require access to a DoD facility or installation. Contractor and all associated subcontractors employees shall comply with adjudication standards and procedures using the National Crime Information Center Interstate Identification Index (NCICIII) and Terrorist Screening Database (Army Directive 201405/AR 19013), applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative); or, at OCONUS locations, in accordance with status of forces agreements and other theater regulations.

6.4.4.4. AT Awareness Training for Contractor Personnel Traveling Overseas. This standard language required US based contractor employees and associated subcontractor employees to make available and to receive Government provided area of responsibility (AOR)-specific AT awareness training as directed by AR 52513. Specific AOR training content is directed by the combatant commander, with the unit ATO being the local point of contact.

6.4.4.5. iWATCH Training. This standard language is for contractor employees with an area of performance within an Army controlled installation, facility or area. The contractor and all associated subcontractors shall brief all employees on the local iWATCH Army program (training standards provided by the requiring activity ATO). This local developed training will be used to inform employees of the types of behavior to watch for and instruct employees to report suspicious activity to the GOVT REP. This training shall be completed within calendar days of contract award and within calendar days of new employees commencing performance with the results reported to the Government Representative NLT calendar days after contract award.

6.4.4.6. Army Training Certification Tracking System (ATCTS) registration for contractor employees who require access to government information systems. All contractor employees with access to a Government info system must be registered in the ATCTS (Army Training Certification Tracking System) at commencement of services, and must successfully complete the DOD Information Assurance Awareness prior to access to the information system and then annually thereafter.

6.4.4.7. For contracts that require a formal OPSEC program. The contractor shall develop an OPSEC Standing Operating Procedure (SOP)/Plan within 90 calendar days of contract award, to be reviewed and approved by the responsible Government OPSEC officer. This plan will include a process to identify critical information, where it is located, who is responsible for it, how to protect it and why it needs to be protected. The contractor shall implement OPSEC measures as ordered by the commander. In addition, the contractor shall have an identified certified Level II OPSEC coordinator per AR 5301.

6.4.4.8. For contracts that require OPSEC Training. Per AR 5301, Operations Security, the contractor employees must complete Level I OPSEC Awareness training. New contractor employees must be trained within 30 calendar days of their reporting for duty and annually thereafter.

6.4.4.9. For IA/IT training. All contractor employees and associated subcontractor employees must complete the DoD IA awareness training before issuance of network access and annually thereafter. All contractor employees working IA/IT functions must comply with DoD and Army training requirements in DoDD 8570.01, DoD 8570.01M and AR 252 within six months of appointment to IA/IT functions.

6.4.4.10. For IA/IT certification. Per DoD 8570.01M , DFARS 252.239.7001 and AR 252, the contractor employees supporting IA/IT functions shall be appropriately certified upon contract award. The baseline certification as stipulated in DoD 8570.01M must be completed upon contract award.

6.4.4.11. For contractors authorized to accompany the force. DFARS Clause 252.2257040, Contractor Personnel Authorized to Accompany U.S. Armed Forces Deployed Outside the United States, shall be used in solicitations and contracts that authorize contractor personnel to accompany US Armed Forces deployed outside the US in contingency operations;

humanitarian or peacekeeping operations; or other military operations or exercises, when designated by the combatant commander. The clause discusses the following AT/OPSEC related topics: required compliance with laws and regulations, pre-deployment requirements, required training (per combatant command guidance), and personnel data required.

6.4.4.12. For Contract Requiring Performance or Delivery in a Foreign Country, DFARS Clause 252.2257043, Antiterrorism/Force Protection for Defense Contractors Outside the US . The clause shall be used in solicitations and contracts that require performance or delivery in a foreign country. This clause applies to both contingencies and non-contingency support. The key AT requirement is for nonlocal national contractor personnel to comply with theater clearance requirements and allows the combatant commander to exercise oversight to ensure the contractor' compliance with combatant commander and subordinate task force commander policies and directives.

6.4.4.13. For contracts that require handling or access to classified information. Contractor shall comply with FAR 52.2042, Security Requirements. This clause involves access to information classified "Confidential, ""Secret," or "Top Secret" and requires contractors to comply with (1) The Security Agreement (DD Form 441), including the National Industrial Security Program Operating Manual (DoD 5220.22M); (2) any revisions to DOD 5220.22M, notice of which has been furnished to the contractor.

6.4.4.14. Cont. If secure telecommunication requirements apply, include clause 252.239-7016 and follow guidance at 239.74.

6.4.4.15. Cont. If covered system support requirements apply, include provision 252.239-7017 into the solicitation, clause 252.239-7018 into the contract, and follow guidance at 239.73.

6.4.4.16. Controlled Unclassified Information (CUI). Include DFARS clause 252.204-7012, which requires the contractor to comply with NIST 800-171. Also include DFARS provision 252.204-2019 into solicitations. Acquisition officials should follow procedures outlined in

DFARS 204.73 and verify vendors have an adequate NIST SP 800-171 summary assessment score within the Supplier Performance Risk System (within PIEE). If the score doesn't show a medium- or high-level assessment with a score of 110 or better (as described in the "NIST SP 800-171 DoD Assessment Methodology"), include clause 252.204-7020 and obtain the vendor's "system security plan" and "plan of action" for NIST SP 800-171 verification and assurance by Army security officials.

6.4.4.17. Threat Awareness Reporting Program. For all contractors with security clearances.

Per AR 381-12 Threat Awareness and Reporting Program (TARP), contractor employees must receive annual TARP training by a CI agent or other trainer as specified in 2-4b.

PART 7

APPLICABLE PUBLICATIONS

7.1 Publications: In addition to the publications listed in the contract, the Contractor shall abide by the following applicable regulations, publications or manuals:

Department of Defense Directive (DoDD) 6459.01, Sexual Assault and Response (SAPR) Program

Force Health Protection Guidance (Supplement 23) Revision 3 - Department of Defense Guidance for Coronavirus Disease 2019 Vaccination Attestation, Screening Testing, and Vaccination Verification

CRDAMC/MEDCEN Command Policy 0039, COVID-19 Healthcare Personnel Sustainment Policy

Public Law:

Public Law 91-596 Occupational Safety and Health Act of 1970

Public Law 104-191 Health Insurance Portability and Accountability Act of 1996

Accreditation Manuals:

The Joint Commission (TJC) Manual (Current Edition)

Defense Health Agency:

DHA-AI 001 Telework Program

DHA-AI 003 Physical Security Program

DHA-AI 034 Drug-Free Workplace Program

DHA-AI 050 Accounting of Disclosures of Personally Identifiable Information (PII) and Protected Health Information (PHI)

DHA-AI 5015.01 Records Management

DHA-AI 5200.02 Information Security Program

DHA-AI 5200.03 Operations Security (OPSEC) Program

DHAPI 6000.03 Life Support Training Certification Requirements and Guidance

DHAPI 6010.02 MHS Prescription Drug Monitoring Program

DHAPI 6015.02 Beneficiary Counseling and Assistance Coordinator (BCAC) and Debt Collection Assistance Officer (DCAO)

DHAPI 6025.04 Pain Management and Opioid Safety in the MHS

DHAPI 6025.06 Standardized Templates for Primary Care Clinical Encounter Documentation

DHAPI 6025.10 Standard Processes, Guidelines, and Responsibilities of the DoD Patient Bill of Rights and Responsibilities in the Military Health System (MHS) Military Medical Treatment Facilities (MTFs)

DHAPI 6025.20 Medical Management (MM) Program within the Military Health System (MHS)

DHAPI 6025.26 Standard Processes for the Military Health System (MHS) Nurse Advice Line

(NAL)

DHAPI 6025.27 Integration of Primary Care Behavioral Health (PCBH) Services into Patient- Centered Medical Home (PCMH) and Other Primary Care Service Settings within the Military Health System (MHS)

DHAPI 6025.28 Standard Processes and Procedures for Communication of Laboratory and Radiology Results

DHAPI 6025.29 Provision of Human Immunodeficiency Virus (HIV) Pre-Exposure Prophylaxis (PrEP) for Persons at High Risk of Acquiring HIV Infection

DHAPI 6025.33 Acupuncture Practice in Military Treatment Facilities

DHAPI 6025.39 Medical Ethics in the Military Health System

DHAPI 6025.42 Routine Adult Transthoracic Echocardiogram (TTE) Standards for all Military Medical Treatment Facilities (MTFs)

DHAPI 6040.07 Medical Coding of the DOD Health Record

DHAPI 6401.01 Dental Sedation Medical Management

DHAPI 6490.02 Behavioral Health (BH) Treatment and Outcomes Monitoring

DHAPM 6025.01 Primary Care Behavioral Health (PCBH) Standards

DHA PM 6025.13, Volumes 1-7 Clinical Quality Management in the Military Health System

Department of Defense (DoD):

DoD 5200.1-R Information Security Program DoD 5200.2 Personnel Security Program

DoDI 5200.46 DoD Investigative and Adjudicative Guidance for Issuing the Common Access Card DoD 5210.42-R Nuclear Weapons Personnel Reliability Program (PRP) Regulation

DoD 5400.7-R DoD Freedom of Information Act

DoD 5400.11-R Department of Defense Privacy Program

DoD 6010.13-M Medical Expense and Performance reporting System for Fixed Military Medical And Dental Treatment Facilities Manual

DoD 6010.15-M Military Treatment Facility Uniform Business Office (UBO) Manual DoD 6015.1- M Glossary of Healthcare Terminology

DoD 6025.18-R DoD Health Information Privacy Regulation

DoD 6055.5-M Occupational Medical Examinations and Surveillance Manual DoD 8580.02-R HIPAA Security Rule

DoDD 5144.02 Information Technology Standards in the DoD DoDD 5205.2 DoD Operations Security (OPSEC) Program

DoDD 5400.11 DoD Privacy Program DoDD 5500.07 Standards of Conduct

DoDD 6000.14 Patient Bill of Rights and Responsibilities in the Military Health System (MHS) DoDD 6040.41 Medical Records Retention and Coding at Military Treatment Facilities

DoDD 6205.02E Policy and Program for Immunizations to Protect the Health of Service Members and Military Beneficiaries

DoDD 8190.3 Smart Card Technology

DoDD 8500.01E Information Assurance

DoDI 1100.22 Policy and Procedures for Determining Workforce Mix

DoDI 1402.5 Criminal History Background Checks on Individuals in Child Care Services DoDI

3020.37 Continuation of Essential DoD Contractor Services During a Crises

DoDI 5200.02 DoD Personnel Security Program (PSP) DoDI 6000.11 Patient Movement

DoDI 6015.23 Delivery of Healthcare at Military Treatment Facilities: Foreign Service Care;

Third Party Collection; Beneficiary Counseling and Assistance Coordinators (BCACs)

DoDI 6025.8 Ambulatory Procedure Visit (APV)

DoDI 6025.13 Medical Quality Assurance (MQA) and Clinical Quality Management in the Military Health System DoDI 6025.18 Privacy of Individual Identifiable Health Information in DoD Health Care Programs

DoDI 6040.40 Military Health System Data Quality Management Control Procedures DoDI

6040.42 Medical Encounter and Coding at Military Treatment Facilities

DoDI 6040.43 Custody and Control of Outpatient Medical Records DoDI 6205.2 Immunization Requirements

PART 8

ATTACHMENTS/EXHIBIT

EXHIBIT 1

PERFORMANCE REQUIREMENTS SUMMARY (PRS)

The following performance outcome acceptable quality levels (AQLs) for minimum quality levels of service are required on this CONTRACT:

Performance Objective

Reference Performance Objective Method of Surveillance

AQL

Overall Fill Rate 5.17.1.1.:

Recruit CSTRs

Percentage of days FTEs are assigned to a positon in a reporting period

100% Inspection by

GOVT REP

90%

On-Time Fill

Percentage

5.17.1.2.:

Place CSTRs

Percentage of FTEs filled by the required start date in the

100% Inspection by

GOVT REP

90%

TO during the reporting period

Turnover Rate 5.17.1.3.:

Replace

CSTRs

The number of FTEs that turned over during a reporting period

100% Inspection by

GOVT REP

90%

Replenish Rate 5.17.1.4.:

Qualifications

CSTR

The measure of how well assigned positions remain filled in a reporting period

100% Inspection by

GOVT REP

90%

ADDITIONAL METRICS

Performance

Objective

Reference Performance Objective

Method of

Surveillance

AQL

Customer

Satisfaction Rate

5.5.1:

Manage

CSTRs

Provide a High Level of

Quality Service and

Minimize Patient Safety

Substantiated

Customer

Complaints

No more than two (2) substantiated complaints in any 12-month period concerns

Complaint

Resolution

Percentage

5.5.6:

Resolve

Performance

Issues

The percentage of discrepancy notices resolved on time in a reporting period

Government management oversight;

discrepancy reports

100%

Comply with

Specific Tasks

5.1., 5.2., 5.1.3.

Comply 100% of the time

Government

Manaagement

Oversight

100%

EXHIBIT 2

DELIVERABLES SCHEDULE

Deliverable Frequency # of Copies

Medium /Format

Submit To

Key Personnel List

NLT 5 business days of TO award

Electronic copy

(MS Word) via email

Go…