Solicitation W912DW21Q0020 LD Medical Surveillances Services.pdf

SEE ADDENDUM

(No Collect Calls)

W912DW21Q0020 29-Jan-2021

b. TELEPHONE NUMBER

206-764-6659

8. OFFER DUE DATE/LOCAL TIME

05:00 PM 28 Feb 2021

5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA – FAR (48 CFR) 53.212

(TYPE OR PRINT)

(SIGNATURE OF CONTRACTING OFFICER)

ADDENDA X ARE

26. TOTAL AWARD AMOUNT (For Gov t. Use Only )

23.

CODE 10. THIS ACQUISITION IS

SUCH ADDRESS IN OFFER

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT

BELOW IS CHECKED

TELEPHONE NO.

W912DW9. ISSUED BY

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a. UNLESS BLOCK

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

GERALDINE L KEMP

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NUMBER

(TYPE OR PRINT)

30b. NAME AND TITLE OF SIGNER 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a.UNITED STATES OF AMERICA

1 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1. 52.212-4. FAR 52.212-3. 52.212-5 ARE ATTACHED.X

25. ACCOUNTING AND APPROPRIATION DATA

1. REQUISITION NUMBER

20.

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

. YOUR OFFER ON SOLICITATION

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

% FOR:SET ASIDE:UNRESTRICTED ORX

SMALL BUSINESS

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

USA ENGINEER DISTRICT, SEATTLE

ATTN: CENWS-CT

4735 EAST MARGINAL WAY SOUTH, BLDG. 1202

SEATTLE WA 98134-2388

18a. PAYMENT WILL BE MADE BY CODE

RATED ORDER UNDER

DPAS (15 CFR 700)

13a. THIS CONTRACT IS A

13b. RATING

CODE15. DELIVER TO CODE 16. ADMINISTERED BY

SEE SCHEDULE

12. DISCOUNT TERMS11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

14. METHOD OF SOLICITATION

RFQ IFB RFPX

206-764-6817FAX:

TEL: SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$12,000,000

NAICS:

621111

X

OFFER DATED

29. AWARD OF CONTRACT: REF.

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

EMAIL:

TEL:

31c. DATE SIGNED

SEE SCHEDULE

SCHEDULE OF SUPPLIES/ SERVICESITEM NO. QUANTITY UNIT UNIT PRICE AMOUNT

24.22.21.19.

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

(CONTINUED)

PAGE 2 OF84

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: ______________________________________________________

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f . TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

37. CHECK NUMBER

FINALPARTIALCOMPLETE

36. PAYMENT35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER

FINAL

33. SHIP NUMBER

PARTIAL

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

Prescribed by GSA – FAR (48 CFR) 53.212

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

SEE SCHEDULE

20.

SCHEDULE OF SUPPLIES/ SERVICES

21.

QUANTITY UNIT

22. 23.

UNIT PRICE

24.

AMOUNT

19.

ITEM NO.

W912DW21Q0020

Section SF 1449 - CONTINUATION SHEET

INSTRUCTIONS

If you have any questions or concerns regarding this Request for Quotation (RFQ), please contact Contract Specialist Ms.Geraldine L Kemp at Geraldine.L.Kemp@usace.army.mil The Government anticipates the award of a non-personal health care services, indefinite quantity, indefinite delivery (IDIQ) single award task order contract (SATOC) to provide medical testing services for the U.S Army Corps of Engineers (USACE) employees Libby Dam Project in Libby, Montana. The anticipated contract will include a base year and three optional years. The maximum capacity for each year is anticipated to be $30,000. The total contract maximum capacity is anticipated to be $120,000. The lifetime contract minimum guarantee will be $500. A task order will be issued immediately at award specifically to obligate this minimum. If the minimum is met by the issue of subsequent order, the original guaranteed minimum task order will be deobligated unilaterally and the order will be closed. If the contractor does not receive a task order prior to the Contract’s expiration of the Base Period that satisfies the guaranteed minimum, they may submit an invoice for the minimum guarantee amount immediately following the Base Period’s expiration date.

1. Award shall be made to the responsive and responsible vendor with the lowest priced quotation that meets all the requirements contained in this Solicitation.

2. The Contractor receiving an award is required to be registered in the System for Award Management (SAM).

Lack of registration in the SAM database will make quote ineligible for award. Registration is available online at www.sam.gov.

3. SUBMISSION OF QUOTATIONS. Please ensure that your quotation arrives prior to due date/time. Quotes shall be submitted per the following:

By Email.

Include the solicitation number and the solicitation title in the email subject line.

Submit to: Geraldine.LKemp@usace.army.mil Faxed quotations will NOT be accepted.

4. Quotes must set forth full, accurate and complete information, as required by this RFQ. Required submittals:

a) Certifications. Submit a copy of certificate of Occupational Medicine for each physician anticipated to perform services under this contract.

b) Completed pricing information for all line items listed in the solicitation.

c) Signed and dated Standard Form 1449 (Solicitation / Contract / Order for Commercial Items).

d) Signed and dated Standard Form 30, if applicable, for any Amendments to the Solicitation.

e) Required items in #5 below.

f) Completed provisions, including: 52.212-3, Offeror Representations and Certifications – Commercial Items (JAN 2017) Alternate I (OCT 2014) (as applicable). Electronic completion is encouraged (see www.sam.gov).

5. The following information is required with quotation submission:

General Contact Information:

Vendor’s Name (Printed): ___________________________________________________________

Vendor’s Complete Address: _________________________________________________________

Vendor’s Telephone Number:_________________________________________________________

Vendor’s Email Address: ____________________________________________________________

Federal Taxpayer Identification (ID) No.: _______________________________________________

CAGE Code Number:_____________________DUNS Number:_____________________________

Is your company registered online in SAM (www.sam.gov)? YES_________ NO___________

Are your Reps and Certs completed in SAM? YES_________ NO___________

If not, please ensure you submit with your quotation.

AMENDMENTS NUMBERED________________ HAVE BEEN RECEIVED

GENERAL REQUIREMENTS

001. GENERAL

This is a non-personal health care services, indefinite quantity, indefinite delivery (IDIQ), single award task order contract (SATOC) to provide medical testing services for the U.S Army Corps of Engineers (USACE) employees at Libby Dam in Libby, Montana. The Contractor shall furnish to USACE all services, labor, materials, and equipment to carry out work specified in task orders. Contractor shall perform services to standards, quantities, and schedules described in each task order, and in accordance with general standards identified in the Performance Work Statement (PWS). Specific taskings shall be performed in accordance with standards, quantities, and schedules described in individual task orders. This Contract may be modified as needed to add deliverable categories in response to authorizing legislation or tasking by other agencies to USACE.

The lifetime contract minimum guarantee is $500. A task order will be issued immediately at award specifically to obligate this minimum. If the minimum is met by the issue of subsequent order, the original guaranteed minimum task order will be deobligated unilaterally and the order will be closed. If the contractor does not receive a task order prior to the Contract’s expiration of the Base Period that satisfies the guaranteed minimum, they may submit an invoice for the minimum guarantee amount immediately following the Base Period’s expiration date.

002. INSURANCE

In accordance with FAR part 37.401(d), the Contractor shall maintain medical liability insurance, in a coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned. The Contractor is required to ensure that its subcontracts for provisions of health care services contain the requirements of the clause at 52.237-7, including the maintenance of medical liability insurance.

The Contractor shall submit to the Contracting Officer evidence of medical liability insurance demonstrating the required coverage prior to the commencement of performance of this contract.

003. ORDERING OF WORK

(A) Ordering Officials. The only person authorized to issue a task order under this contract is a warranted Contracting Officer. The Contracting Officer who signed this contract is the primary Contracting Officer for the contract. Nevertheless, any Contracting Officer assigned to the Seattle District and acting within his/her authority may take formal action on this contract when a contract action needs to be taken and the primary Contracting Officer is unavailable. Any task order issued by someone other than the Contracting Officer is void and unenforceable, meaning the Government is NOT responsible for any costs incurred and the Contractor bears the entire risk of loss.

(B) Issuance of a Task Order. Whenever Libby Dam requires employee(s) to get their medical clearance examinations, the Contracting Officer will issue a funded task order under this contract. This task order will include a Statement of Work (SOW). The SOW will normally include: (1) the nature of the work to be performed (anticipated of exams required); (2) the potential number of employees who will require appointments; (3) the approximate time period the exams will be scheduled; (4) any other (non-personal) information needed for the doctor.

(C) Scheduling of Exams. Once a task order has been issued by the Contracting Officer and received by the Contractor, Libby Dam’s USACE Operating Project Administrative Officer (AO) or their designated substitute or replacement (should the AO be unavailable) will contact the Contractor to schedule the dates of their employee’s examination appointments. The AO will provide the Contractor with all pertinent information for each patient (including personally identifiable information).

(D) Employee Medical Examinations. When the USACE employee arrives at their medical examination at the Contractor’s facility, they will present the completed Medical Surveillance Examination Requirements form (Technical Exhibit 4 of the PWS) to the Contractor’s medical staff at the time of their examination. This form states the necessary tests they will require (see PWS section 5 for details). The Government may evaluate the quality of professional and administrative services provided, but retains no control over the medical and professional aspects of services rendered (e.g., professional judgments, diagnosis for specific medical treatment).

004. CONTRACT MANAGEMENT

The Contractor must implement necessary work control procedures to ensure an accurate tracking of the medical exams given on a monthly basis. This includes any additional medical exams recommended by the doctor that was not originally anticipated and/or not specified in this contract. These additional exams, deemed necessary by the doctor in order for the USACE employee to receive their medical clearance letter, require a request for approval from the Contractor to the USACE Operating Project Administrative Officer (AO) before the exam can be performed. The Contractor can place this request either via telephone or email. The Contractor shall also:

(a) Provide an adequate staff of personnel point of contact(s) that USACE can consistently reach during normal business hours (specified in 1.6.3 of the PWS) regarding scheduling of exams, contract requirements, clearance letters, issues and billing questions. Contractor shall provide their point of contact’s (POC’s) contact information to the Contracting Officer and Libby Dam’s USACE Operating Project Administrative Officer (AO) upon the award of this contract.

(b) Send USACE employee clearance letters to Libby Dam’s USACE Operating Project Administrative Officer (AO) and copy shall also be sent to the USACE Seattle District Safety Office Chief within the time limits and the format in accordance with Part 5 – SPECIFIC TASKS of the PWS.

(c) Agree to hold the Government harmless and indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring contract performance.

005. TRAVEL

Auto Mileage Website: http://www.defensetravel.dod.mil/site/otherratesMile.cfm

Per Diem Website: http://www.defensetravel.dod.mil/site/perdiemCalc.cfm

As stated in section 1.6.4 – Place of Performance of the PWS, the Contractor is required to travel to Chief Joseph Dam to perform the medical examinations on-site. As prescribed in FAR 31.205-46, travel costs incurred for travel in the Continental United States, Alaska, Hawaii, The Commonwealth of Puerto Rico, and territories and possessions of the United States, shall not exceed on a daily basis the maximum per diem rates in effect at the time of travel as set forth in the Joint Travel Regulations, Volume 2, DoD Civilian Personnel, Appendix A, prescribed by the Department of Defense. Travel/transportation rates will be negotiated with each task.

PRICING SCHEDULE

Total quantities identified in the pricing schedule are associated with the principal Current Procedural Terminology (CPT), ancillary CPTs relative to the principal is implicit. Fixed rates shall include wages, overhead, general and administrative expense and profit (fully burdened). The number of tests in the pricing spreadsheets are approximate and are included to tabulate a price for comparison in the evaluation process.

BASE YEAR

TASK DESCRIPTION

Number of Exams

Unit Price (EA) Total Cost

1 Hazardous Waste Worker 2

2 Pesticide Applicator 2

3 Asbestos Worker 8

4 Crane Operator 7

5 Commercial Drivers’ License 7

6 Coast Guard Licenses Holders 0

7 Employees Exposed to Lead and Zinc 0

Employees with Potential Bloodborne Pathogen Exposures

9 Respiratory Clearance to include PFT 21

10 Employees Exposed to Chromium VI 6

Employees Exposed to Vision Hazards or Requiring Visual Acuity

12 (Non-ionizing) Radiation Worker 0

13 Lock Operator 0

14 Welder 6

15 Painter 0

16 Arbovirus Exposure 0

Periodic surveillance for employee exposure to Be, Cd, and other heavy metals

TBD

18 Employees Exposed to Noise 20

Pre-placement exam for new or transfer personnel

Post treatment after an exposure to blood borne pathogens

TOTAL AMOUNT

OPTION YEAR ONE (1)

Number of Exams

Unit Price (EA) Total Cost

1 Hazardous Waste Worker 2

2 Pesticide Applicator 2

3 Asbestos Worker 8

4 Crane Operator 7

5 Commercial Drivers’ License 7

6 Coast Guard Licenses Holders 0

7 Employees Exposed to Lead and Zinc 0

Employees with Potential Bloodborne

Employees Exposed to Vision Hazards or

14 Welder 6

15 Painter 0

16 Arbovirus Exposure 0

Periodic surveillance for employee exposure to

Pre-placement exam for new or transfer

OPTION YEAR TWO (2)

Number of Exams

Unit Price (EA) Total Cost

1 Hazardous Waste Worker 2

2 Pesticide Applicator 2

3 Asbestos Worker 8

4 Crane Operator 7

5 Commercial Drivers’ License 7

6 Coast Guard Licenses Holders 0

7 Employees Exposed to Lead and Zinc 0

Employees with Potential Bloodborne

Employees Exposed to Vision Hazards or

14 Welder 6

15 Painter 0

16 Arbovirus Exposure 0

Periodic surveillance for employee exposure to

Pre-placement exam for new or transfer

OPTION YEAR THREE (3)

Number of Exams

Unit Price (EA) Total Cost

1 Hazardous Waste Worker 2

2 Pesticide Applicator 2

3 Asbestos Worker 8

4 Crane Operator 7

5 Commercial Drivers’ License 7

6 Coast Guard Licenses Holders 0

7 Employees Exposed to Lead and Zinc 0

Employees with Potential Bloodborne

Employees Exposed to Vision Hazards or

14 Welder 6

15 Painter 0

16 Arbovirus Exposure 0

Periodic surveillance for employee exposure to

Pre-placement exam for new or transfer

Performance Work Statement (PWS)

Medical Surveillance Services for Libby Dam Libby, MT 59923

Table of Contents

SECTION 1: GENERAL INFORMATION/DESCRIPTION OF SERVICES

1. Introduction:

1.1. Background:

1.2. Purpose/Objective:

1.3. Applicable Publications:

1.4. Ordering Procedures:

1.5. Hours of Operation:

1.6. Recognized Holidays:

1.7. Place of Performance:

1.8. Government Furnished Equipment:

1.9. Ordering Period:

1.10. Direct and Indirect Costs:

1.11. Safety Requirements:

SECTION 2: PERFORMANCE REQUIREMENTS AND RESPONSIBILITIES

2. CONTRACT ADMINISTRATION:

2.1. Insurance:

2.2. Privacy:

2.3. Staffing / Testing Standards:

2.4. Record Keeping:

2.5. Personal Protective Equipment:

2.6. Government Key Personnel:

2.7. Contractor Point of Contact:

2.8. Post Award Conference / Periodic Meetings:

SECTION 3: SCOPE OF WORK

3. SPECIFIC TASKS:

3.1. Estimated Workload:

3.2. Clearance Letters:

3.3. Submittal Invoices:

SECTION 4: APPENDIXES AND ATTACHMENTS

DEFINITIONS AND ACRONYMS:

SECTION 1: GENERAL INFORMATION/DESCRIPTION OF SERVICES

1. Introduction: This is a non-personal health care services single award task order (SATOC) indefinite quantity, indefinite delivery (IDIQ) contract (see FAR 52.216-22) to provide medical testing services for the U.S Army Corps of Engineers (USACE) employees at Libby Dam (LD) in Libby, Montana. The Government may evaluate the quality of professional and administrative services provided, but retain no control over the medical professional aspects of services rendered such as testing procedures, etc. The Contractor will provide Board Certified Occupational Health Physician(s), supervision, all labor, tools, materials, equipment, and incidentals required to conduct the Medical Surveillance Examination / Occupational Health Services.

The guidelines and conditions identified below represent the Government’s minimum requirements and do not relieve the Contractor of responsibility of complying with all federal, state and local laws pertaining to the performance and accomplishment of the services identified throughout this contract. Any reference to a federal, state or local law or regulation within this contract is for emphasis only and does not relieve the Contractor of the obligation to be aware of and comply with all applicable federal, state and local county laws and regulations.

1.1. Background: The U.S. Army Corps of Engineers (USACE) is required to provide medical surveillance and clearance testing services for their employees for safety/readiness purposes. Medical surveillance testing services and examinations include pre-employment and separation physicals, medical surveillance and periodic medical clearance examinations of employees to meet regulatory requirements based on employee job descriptions, exposures, and job tasks. USACE uses the guidelines of 29 CFR 1910, EM 385-1-1, ER-385-1-40 and ER 385-1-89.

1.2. Purpose/Objective: The purpose of the Occupational Medical Surveillance Examination Program is to provide job-related Medical Surveillance Examinations and Occupational Health Services to LD employees who are or could potentially be exposed to health hazards in the work environment. The examination shall include personnel assigned to positions requiring specific standards of physical fitness.

All medical reports/results require a review by a doctor who is certified or board eligible in Occupational Health.

This requirement shall be maintained for the length of the contract.

1.3. Applicable Publications:

- EM 385-1-1 (2014), USACE Safety and Health Requirements Manual

- 29 CFR 1910, Occupational Safety and Health Administration

- ER 385-1-40, Occupational Health Program

- ER 385-1-89, Hearing Conservation Program

1.4. Ordering Procedures: Task orders will be issued by the Government as the need arises during the contract ordering period. Individual task orders under this contract will describe actual services to be performed for specific services. The Government makes no guarantee as to the total amount of services to be required and reserves the right to require no services during the ordering period.

The Contractor is advised not to perform any services under this contract resulting in a change of work or services that affects the price of a task order unless previously negotiated and/or approved by the Contracting Officer (KO).

1.5. Hours of Operation: The Contractor is responsible for setting their own hours of business. However, the Contractor must provide adequate support to achieve required performance objectives of section 3 for the duration of the performance period. The Government will schedule appointments prior to sending employees during normal hours of business: Monday through Thursday, 0630-1700 (Mountain Time).

1.6. Recognized Holidays: The Contractor is not required to conduct work on the following Federal holidays:

New Year’s Day Labor Day Martin Luther King Jr.’s Birthday Columbus Day President’s Day Veteran’s Day Memorial Day Thanksgiving Day Independence Day Christmas Day

1.7. Place of Performance:

Option 1: Work performed under this contract will be performed at the contractor’s facility within 100 miles of LD.

Option 2: A majority of this work will pe performed at the contractor’s facility within 100 miles of LD and audiograms will be performed at LD at a location determined by the LD Safety Officer.

LD is located at the following address: Libby Dam, 17877 Mt. Hwy 37, Libby, MT 59923-7828

1.8. Government Furnished Equipment: The Government will provide facility space at Libby Dam to be used to fulfill the requirements as outlined in this document.

1.9. Ordering Period: This contract has one (1) twelve (12) month base year and three (3) twelve (12) month option year periods.

Base Year: 15 March 2021 – 14 March 2022 Option Year 1: 15 March 2022 – 14 March 2023 Option Year 2: 15 March 2023 – 14 March 2024 Option Year 3: 15 March 2024 – 14 March 2025

1.10. Direct and Indirect Costs: All costs incurred by the Contractor related to the performance of contract work are the responsibility of the Contractor. All travel costs that may be required during the duration of this contract will be the responsibility of the Contractor.

1.11. Travel

Auto Mileage: http://www.defensetravel.dod.mil/site/otherratesMile.cfm

Per Diem: http://www.defensetravel.dod.mil/site/perdiemCalc.cfm

The Contractor is required to travel to Libby Dam under Option 2 of Section 1.7 to perform the medical examinations on-site. As prescribed in FAR 31.205-46, travel costs incurred for travel in the Continental United States, Alaska, Hawaii, The Commonwealth of Puerto Rico, and territories and possessions of the United States, shall not exceed on a daily basis the maximum per diem rates in effect at the time of travel as set forth in the Joint Travel Regulations, Volume 2, DoD Civilian Personnel, Appendix A, prescribed by the Department of Defense.

Travel/transportation rates will be negotiated with each task.

1.12. Safety Requirements: The Contractor shall conform to applicable OSHA, and State of Washington, standards, as well as USACE of Engineers Safety Requirements Manual (EM 385-1-1), available here: EM 385-1- 1.pdf. Compliance with Occupational Safety and Health Act (OSHA), and other applicable laws and regulations for the protection of Contractor employees is exclusively the Contractor’s obligation, and the Government will assume no liability or responsibility for the Contractor’s compliance or non-compliance with such responsibilities.

1.12.1. Safety Plan: A safety plan may be required for some task orders. The plan shall include, but not be limited to, description of steps that will be taken to comply with USACE safety requirements as outlined in EM 385-1-1.

1.13. Organization Conflict of Interest: Contractor and subcontractor personnel performing work under this contract may receive, have access to or participate in the development of proprietary or source selection information (e.g., cost or pricing information, budget information or analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent Organizational Conflict of Interests (OCI) as defined in FAR Subpart 9.5.

1.14. Security Requirements: All contractor and all associated sub-contractor employees shall comply with applicable installation, facility and area commander installation/facility access and local security policies and procedures (provided by government representative). The contractor shall also provide all information required for background checks to meet installation/facility 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 52.204-9, 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 installation or facility change, the Government may require changes in contractor security matters or processes.

The Contractor must pre-screen Candidates using the E-verify Program (http://www.uscis.gov/e-verify) website to meet the established employment eligibility requirements. The Vendor must ensure that the Candidate has two valid forms of Government issued identification prior to enrollment to ensure the correct information is entered into the E-verify system. An initial list of verified/eligible Candidates must be provided to the COR no later than 3 business days after the initial contract award." *When contracts are with individuals, the individuals will be required to complete a Form I-9, Employment Eligibility Verification, with the designated Government representative. This Form will be provided to the Contracting Officer and shall become part of the official contract file.

SECTION 2: PERFORMANCE REQUIREMENTS AND RESPONSIBILITIES

2. CONTRACT ADMINISTRATION: The Government will evaluate the Contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). The QASP will be used as a basis for evaluation. Failure to adequately complete any service or submittal to at least a satisfactory level of quality and timeliness may result in repeat of work, a poor performance evaluation, or both. The QASP is primarily focused on what the Government will do to ensure that the Contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

2.1. Insurance: This contract is for non-personal health care services as defined in 37.101. In accordance with FAR Part 37.4 the Government may enter a non-personal health care services contract with physicians, dentists and other health care providers under authority of 10 U.S.C. 2304 and 41 U.S.C. 253. The Government shall evaluate the quality of professional and administrative services provided, while the Government retains no control over the medical, professional aspects of services rendered. The Contractor will indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance. The Contractor will maintain medical liability insurance, in a coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned. The Contractor is required to ensure that its subcontractors, if any, for provisions of health care services, contain the requirements of the clause at 52.237-7, Indemnification and Medical Liability Insurance, including the maintenance of medical liability insurance. The contractor, upon request by the Contracting Officer, shall furnish prior to contract award evidence of its insurability concerning the medical liability insurance required by this clause.

2.2. Privacy: The Contractor shall ensure that all findings are clearly recorded on Government or other approved forms and are protected by Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated safeguards to ensure confidentiality of health information.

Contractor shall identify all medical records with the employee’s full name, social security number, date of birth, and the name of the employee’s workplace or facility at a minimum. The contractor shall ensure work / health history forms and medical reports are complete and legible (typed / printed).

2.3. Staffing / Testing Standards: All medical surveillance and clearance examinations reports shall be reviewed, signed, and approved by a physician that is Board Certified or Board eligible in Occupational Medicine.

Contractor shall ensure all procedures are conducted in accordance with applicable American Board of Occupational and Environmental Medicine (ABOEM), American Association of Occupational Health Nurses (AAOHN), U.S.

Department of Labor, Occupational Safety and Health Administration (OSHA), and the National Institute for Occupational Safety and Health (NIOSH) Standards.

2.4. Record Keeping: The contractor shall act as the medical records custodian for all medical records as generated by the performance of this contract for the duration of this contract. Potential duties to include answering document requests and holding a complete file of all records at the contractor’s facility. At the conclusion of this contract, the Government shall provide the contractor a forwarding point of contact for the transference of all files or records.

2.5. Personal Protective Equipment: Contractor shall furnish and assure healthcare workers are provided with the appropriate PPE such as, but not limited to gloves, protective eyewear, and masks, where there is a potential for exposure to blood or other potentially infectious materials.

2.6. Government Key Personnel:

USACE Contracting Officer (KO) – Identified person is responsible for the oversight and execution of this contract.

LD Safety Officer – Identified person serves as the Contractor’s main point of contact for the execution of this contract. Duties to include scheduling exams and receipt of clearance letters as required in part 3 of this PWS.

Additionally, this person maintains written and oral communications with the Contractor concerning technical aspects of the contract, and monitor Contractor’s performance.

USACE Chief of Seattle District Safety Office – Identified person shall receive a copy of every clearance letter as required by part 3 of this PWS.

2.7. Contractor Point of Contact: The Contractor shall provide a point of contact who shall be responsible for assisting in the scheduling of exams/appointments and replying to any inquiries that may arise as result of the work performed by this contract. The name of this person and an alternate who shall act for the Contractor when the point of contact is absent shall be designated in writing to the contracting officer. The Contractor shall immediately notify the contracting officer and the LD Safety Officer if the Contractor’s point of contact or alternate change.

2.8. Post Award Conference / Periodic Meetings: The Contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. Government personnel, as appropriate, may meet periodically with the Contractor to review the Contractor's performance. These meetings shall be at no additional cost to the Government.

SECTION 3: SCOPE OF WORK

3. SPECIFIC TASKS: No work shall be performed prior to the award of a task order. Task orders may include any of the tasks set out below for management of medical surveillance on LD. Under this contract, some, none, or all the tasks presented herein may be ordered for delivery to the Government. Employees will provide the doctor with specific guidance relevant to their personal exposures and content of their exam.

3.1. Estimated Workload: Medical Surveillance, clearance testing, and lab services as required by this contract are the following:

Task 1: Hazardous Waste Worker, estimated quantity: 2 Task 2: Pesticide Applicator, estimated quantity: 2 Task 3: Asbestos Worker, estimated quantity: 8 Task 4: Crane Operator, estimated quantity: 7 Task 5: Commercial Drivers’ License, estimated quantity: 7 Task 6: Coast Guard Licenses Holders – Platforms, Tugs, or Commercial Watercraft Pilots or Captains, estimated quantity: 0 Task 7: Employees Exposed to Lead, estimated quantity: 0 Task 8: Employees with Potential Bloodborne Pathogen Exposures, estimated quantity: 10 Task 9: Respirator User, estimated quantity: 21 Task 10: Employees Exposed to Chromium VI, estimated quantity: 6 Task 11: Employees Exposed to Vision Hazards or Requiring Visual Acuity, estimated quantity: 1 Task 12: (Non-ionizing) Radiation Worker, estimated quantity: 0 Task 13: Lock Operator, estimated quantity: 0 Task 14: Welder, estimated quantity: 6 Task 15: Painter, estimated quantity: 0 Task 16: Arbovirus Exposure, estimated quantity: 0 Task 17: Pre-placement exam and periodic surveillance for exposure to Be, Cd, and other heavy metals, estimated quantity: TBD Task 18: Employees Exposed to Noise, estimated quantity: 20 Task 19: Pre-placement Exam for New or Transfer Employees and annual exam there after (for the trades), estimated quantity: TBD Task 20: Post treatment after an exposure to blood borne pathogens, estimated quantity: TBD

3.2. Clearance Letters: All the above tasks require a medical clearance letter following the exam within 3 weeks of the date of the exam EXCEPT for the following:

Employee Exposed to Noise. If a Significant Threshold Shift is detected during this task, the Project Safety Officer must be notified within 10 calendar days so that a follow up exam can be scheduled.

Pre-placement Exam for New or Transfer Employees. This task requires a medical clearance letter within 5 calendar days of the date of the exam.

Post treatment after an exposure to blood borne pathogens. No clearance letter required

The original copy of all clearance letters shall be sent by hard copy US Mail to the Project Safety Officer and a copy shall be sent via encrypted e-mail to the USACE Seattle District Safety Office Chief and the Project Safety Officer:

Project Safety Officer: Mr. Garrett Wickham, Garrett.C.Wickham@usace.army.mil, Libby Dam, 17877 Mt. Hwy 37, Libby, MT 59923-7828

USACE Seattle District Safety Office Chief: Mr. Richard Perry, Richard.A.Perry@usace.army.mil, 4735 E Marginal Way S BLDG 1202, Seattle, WA 98134

3.3. Submittal Invoices: The Contractor shall furnish invoices as required to the LD Safety Officer; evidencing performance of work done under this contract. The invoice must include the following information:

Contract number;

Task Order number;

Project name;

Amount for each line item, Line item description with CPT code.

SECTION 4: APPENDIXES AND ATTACHMENTS

Appendix A: Medical Surveillance Examination – Procedure Request Form Appendix B: Template Medical Questionnaire Attachment 1: Optional Form (OF) 178: Certificate of Medical Examination Attachment 2: Quality Assurance and Performance Requirement Summary

APPENDIX A: Medical Surveillance Examination – Procedure Request Form

Employee Name: _______________________ Date: ______________

Clearances Required (Check for Yes) Respirator Commercial Driver’s License

Crane Operator U.S. Coast Guard

Name of Test Current Procedural

Terminology (CPT) Check for Yes

Leave blank for No Work-related exam w/ work history

99456

DoT Commercial Driver License exam 99214

Audiogram 92552

Lab-CBC w/ differential (not needed when a General Health Panel is ordered) 85025

Visual Acuity 99173

Chest X-Ray 2 Views (asbestos) 71020

X-Ray B-reading (asbestos) 71250

General Health Panel (Complete Blood Count(CBC), Comprehensive

Metabolic Count (CMP) & Thyroid tests.

80050

Thyroxine 84439

Urinalysis w/ microscopy 81015

Cadmium 82300

Venipuncture 36415

Lab - Heavy Metal Blood (Use specific heavy metal quantitative code instead of

83018 when available.)

83018

Zinc 84630

Chromium 82495

Lab – Nickel Blood Test 83885

Hep B – Adult 90746

Hep A - Adult 90632

Tetanus / Diptheria (Tdap) 90715

Lead & Zinc OSHA 84202

The following tests shall be completed only after receiving approval from the Administrative Officer or their designee.

Test Current Procedural Terminology (CPT)

Authorization received (Y/N)

EKG Complete 93000

Cardiovascular Stress Test 93015

Safety Officer: ___________ _____________ Date: ______

When completed the Safety Officer will provide a scanned copy to the District Safety and Occupational Health Office and the employee shall present the completed form to the medical staff at the time of their examination.

APPENDIX B: Template Medical Questionnaire

Medical Questionnaire for Respiratory Protection

INITIAL MEDICAL QUESTIONNAIRE

1. Name ________________________________________________________________

2. Social Security Number # ____________________________________________

3. Present occupation __________________________________________________

4. Project _______________________________________________________________

5. Address _____________________________________________________________

6. Telephone number ____________________________________________________

7. Interviewer _________________________________________________________

8. Date ________________________________________________________________

9. Date of Birth (month/Day/Year): ___________________________________________

10. Place of Birth ______________________________________________________

11. Sex (Circle): Male Female

12. Marital status (Circle): Single Separated Married Divorced Widowed

13. Race (circle): White Hispanic Black Native American Asian Other

14. What is the highest grade completed in school? _____________________

OCCUPATIONAL HISTORY

15. Have you ever worked full time (30 hours per week or more) for 6 months or more? Yes No

IF YES: A. Have you ever worked for a year or more in any dusty job? Yes No Does Not Apply

Specify job/industry _______________ Total Years Worked __________

Was exposure: Mild Moderate Severe

B. Have you ever been exposed to gas or chemical vapors in your work? Yes No Specify job/industry ______________________ Total Years Worked ___

Was exposure: Mild Moderate Severe

C. What has been your usual occupation or job -- the one you have worked at the longest?

Job occupation _____________________________________________

Number of years employed in this occupation ____________________

Position/job title ____________________________________________

Business, field or industry _____________________________________

(Record on lines the years in which you have worked in any of these industries, e.g. 1960-1969)

PAST MEDICAL HISTORY

16. Do you consider yourself to be in good health? Yes / No If "NO" state reason:

17. Have you any defect of vision? Yes / No If "YES" state nature of defect:

18. Have you any hearing defect? Yes / No If "YES" state nature of defect:

Yes No Are you suffering from or have you ever suffered from Epilepsy/seizures?

Are you suffering from or have you ever suffered from Rheumatic fever?

Are you suffering from or have you ever suffered from Kidney disease?

Are you suffering from or have you ever suffered from Bladder disease?

Are you suffering from or have you ever suffered from Diabetes?

Are you suffering from or have you ever suffered from Jaundice?

CHEST COLDS AND CHEST ILLNESSES

19. If you get a cold, does it "usually" go to your chest? (Usually means more than 1/2 the time)

Yes No Don't get colds

20. During the past 3 years, have you had any chest illnesses that have kept you off work, indoors at home, or in bed? Yes No

IF YES: A. Did you produce phlegm with any of these chest illnesses? Yes No Does Not Apply

B. In the last 3 years, how many such illnesses with (increased) phlegm did you have which lasted a week or more?

Number of illnesses _______ No such illnesses ________

21. Did you have any lung trouble before the age of 16? Yes No

22. Have you ever had any of the following?

A. Attacks of bronchitis? Yes No

IF YES: Was it confirmed by a doctor? Yes No

Have you ever worked: YES NO Years In a mine?

In a quarry?

In a foundry?

In a pottery?

In a cotton, flax or hemp mill?

With asbestos?

At what age was your first attack? Age in Years ______

B. Pneumonia (include bronchopneumonia)? Yes No

At what age did you first have it? Age in Years ______

C. Hay Fever? Yes No

At what age did it start? Age in Years ______

23. Have you ever had chronic bronchitis? Yes No

IF YES: A. Do you still have it? Yes No

B. Was it confirmed by a doctor? Yes No

C. At what age did it start? Age in Years ______

24. Have you ever had emphysema? Yes No

C. At what age did it start? Age in Years _______

25. Have you ever had asthma? Yes No

C. At what age did it start? Age in Years ______

D. If you no longer have it, at what age did it stop? Age stopped _____

26. Have you ever had?

A. Any other chest illness? Yes No If yes, please specify ___________________________________________

B. Any chest operations? Yes No If yes, please specify ___________________________________________

C. Any chest injuries? Yes No

If yes, please specify ___________________________________________

27. Has a doctor ever told you that you had heart trouble? Yes No

IF YES: Have you ever had treatment for heart trouble in the past 10 years?

28. Has a doctor told you that you had high blood pressure? Yes No

IF YES: Have you had any treatment for high blood pressure (hypertension) in the past 10 years? Yes

No

29. When did you last have your chest X-rayed? (Year) _____________________________

30. Where did you last have your chest X-rayed (if known)?

What was the outcome? _______________________________________________

FAMILY HISTORY

31. Were either of your natural parents ever told by a doctor that they had a chronic lung condition such as:

Father Mother Yes No Don’t know Yes No Don’t know A. Chronic Bronchitis B. Emphysema

C. Asthma

D. Lung Cancer

E. Other chest conditions F. Is parent currently alive

G. Please specify Age if living:

Age at Death:

Don’t know

Age if living:

Age at Death:

Don’t know

H. Please specify the cause of death

COUGH

32. Do you usually have a cough? (Count a cough with first smoke or on first going out of doors. Exclude clearing of throat.) (If no, skip to question 32 C.) Yes No

A. Do you usually cough as much as 4 to 6 times a day 4 or more days out of the week? Yes No

B. Do you usually cough at all on getting up or first thing in the morning? Yes No

C. Do you usually cough at all during the rest of the day or at night? Yes No

IF YES TO ANY OF ABOVE (34, A, B, OR C), ANSWER THE FOLLOWING. IF NO TO ALL, CHECK

____ DOES NOT APPLY AND SKIP TO QUESTION 33.

D. Do you usually cough like this on most days for 3 consecutive months or more during the year? Yes No

E. For how many years have you had the cough? Number of years ______

33. Do you usually bring up phlegm from your chest? (Count phlegm with the first smoke or on first going out of doors. Exclude phlegm from the nose. Count swallowed phlegm.) (If no, skip to 33 B)

Yes No

A. Do you usually bring up phlegm like this as much as twice a day 4 or more days out of the week? Yes No

B. Do you usually bring up phlegm at all on getting up or first thing in the morning? Yes No

C. Do you usually bring up phlegm at all on during the rest of the day or at night? Yes No

IF YES TO ANY OF THE ABOVE (33, A, B, OR C), ANSWER THE FOLLOWING: IF NO TO ALL,

CHECK

_____ DOES NOT APPLY AND SKIP TO 36.

D. Do you bring up phlegm like this on most days for 3 consecutive months or more during the year?

Yes No Does Not Apply

E. For how many years have you had trouble with phlegm? Number of years ___ Does not apply

EPISODES OF COUGH AND PHLEGM

34. Have you had periods or episodes of (increased*) cough and phlegm lasting for 3 weeks or more each year?*(For persons who usually have cough and/or phlegm) Yes No

IF YES: A. For how long have you had at least 1 such episode per year?

Number of years ______

WHEEZING

35. Does your chest ever sound wheezy or whistling…

A. When you have a cold? Yes No

B. Occasionally apart from colds? Yes No

C. Most days or nights? Yes No

IF YES TO A, B, or C: For how many years has this been present?

Number of years _____ Does not apply

36. Have you ever had an attack of wheezing that has made you feel short of breath? Yes No IF YES: A. How old were you when you had your first such attack? Age in years _____

B. Have you had 2 or more such episodes? Yes NO

C. Have you ever required medicine or treatment for the(se) attack(s)? Yes No

BREATHLESSNESS

37. If disabled from walking by any condition other than heart or lung disease, please describe and proceed to question 39.

Nature of condition(s):

38. Are you troubled by shortness of breath when hurrying on the level or walking up a slight hill?

IF YES: A. Do you have to walk slower than people of your age on the level because of breathlessness?

B. Do you ever have to stop for breath when walking at your own pace on the level? Yes No

C. Do you ever have to stop for breath after walking about 100 yards (or after a few minutes) on the level? Yes No

D. Are you too breathless to leave the house or breathless on dressing or climbing one flight of stairs? Yes No

TOBACCO SMOKING

39. Have you ever smoked cigarettes? (No means less than 20 packs of cigarettes or 12 oz. of tobacco in a lifetime or less than 1 cigarette a day for 1 year.) Yes No

IF YES: A. Do you now smoke cigarettes (as of one month ago) Yes No

B. How old were you when you first started regular cigarette smoking? Age in years___

C. If you have stopped smoking cigarettes completely, how old were you when you stopped? Age stopped___ Check if still smoking ___

D. How many cigarettes do you smoke per day now?

Cigarettes per day___ Does not apply___

E. On the average of the entire time you smoked, how many cigarettes did you smoke per day?

Cigarettes per day___

F. Do or did you inhale the cigarette smoke?

Not at all___ Slightly___ Moderately___ Deeply___

40. Have you ever smoked a pipe regularly? (Yes means more than 12 oz. of tobacco in a lifetime.)

IF YES: A. How old were you when you started to smoke a pipe regularly? Age ___

B. If you have stopped smoking a pipe completely, how old were you when you stopped? Age stopped___ Check if still smoking pipe___

C. On the average over the entire time you smoked a pipe, how much pipe tobacco did you smoke per week? ___ oz. per week (a standard pouch of tobacco contains 1 1/2 oz.)

D. How much pipe tobacco are you smoking now?

oz. per week___ Not currently smoking a pipe ___

E. Do you or did you inhale the pipe smoke?

Not at all___ Slightly___ Moderately___ Deeply ___

41. Have you ever smoked cigars regularly? (Yes means more than 1 cigar a week for a year) Yes No

IF YES: A. How old were you when you started smoking cigars regularly? Age _____

B. If you have stopped smoking cigars completely, how old were you when you stopped?

Age ___ Check if you are still smoking cigars___

C. On the average over the entire time you smoked cigars, how many cigars did you smoke per week? Cigars per week ___

D. How many cigars are you smoking per week now?

Cigars per week ___ Check if not smoking cigars currently___

E. Do or did you inhale the cigar smoke?

Not at all___ Slightly___ Moderately___ Deeply___

Signature ____________________________ Date _____________________

DEFINITIONS AND ACRONYMS:

Contracting Officer (KO): The Government employee who is authorized to enter, administer, and/or terminate contracts and make related determinations and findings. The only individual who can legally bind the Government.

Current Procedural Terminology (CPT): Uniform information about medical services and procedures among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes.

Engineer Manual (EM) 385-1-1 Safety and Health Requirements Manual: This manual prescribes the safety and health requirements for all Corps of Engineers activities and operations and applies to all military, civilian or contractor personnel.

Federal Acquisition Regulation (FAR): The Federal Acquisition Regulation (FAR), 48 CFR Chapter 1, is the principal set of rules in the Federal Acquisition Regulation System. The FAR System governs the "acquisition process" by which the federal Government purchases (acquires) goods and services.

Health Insurance Portability and Accountability Act (HIPPA) of 1996: Public Law 104-191; U.S. law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers.

Industrial Hygiene (IH): The science and art devoted to anticipation, recognition, evaluation, prevention and control of those environmental factors or stresses arising in or from the workplace or the community that may cause sickness, impaired health and well-being, or significant discomfort among workers.

Medical Surveillance: The ongoing, systematic collection, analysis and interpretation of data derived from instances of medical care or medical evaluation, and the reporting of population-based information…