Vision Examination Statement of Work - Draft.pdf

OHIO ARMY NATIONAL GUARD

TY20 STATEMENT OF WORK

Vision Examination

OHIO ARMY NATIONAL GUARD

1. Intent. The purpose of this agreement is to establish pre‐priced, specialized vision examination at locations in Columbus, Ohio and North Canton, Ohio. Vision examinations are ordered on an infrequent but reoccurring basis in accordance with FAR Part 37.4. The Ohio Army National Guard (OHARNG) requires Service Members to complete specialty vision examinations for specific jobs within the organization. Each type of vision examination has individual requirements. Specifications for each type of physical examination is outlined in Table 1 – Summary of Requirements for OHARNG Vision Examinations. Vision examinations will be priced and ordered by type.

2. Standards: The Government shall evaluate the quality of professional and administrative services provided, while the Government retains no control over the 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 a 52.237‐7, Indemnification and Medical Liability Insurance, including the maintenance of medical liability insurance.

2.1. Examiner Requirements. A licensed optician can perform all required examinations.

3. Payment of Services. The Contractor shall submit an invoice detailing the services rendered, date of services and name of examinee in accordance with DFARS 252.232‐7003. See BPA Terms & Conditions for specific details. This agreement does not fiscally bind the Government or Contractor, as that transaction will occur on a per CALL basis where funds are obligated and disbursed.

4. Physical Exam Process

4.1. Purchase Requests. Program managers will identify personnel requiring physicals listed in Table 1.

They will construct a Purchase Request (PR) package with roll‐up roster that includes full name, unit, type of vision examination, email address and phone number of the Service Member requiring an exam.

The roster will be attached in GFEBS and submitted to the Purchasing and Contracting (P&C) office. PRs shall be submitted monthly. Once a funded package, and roll‐up are obtained, the P&C office will issue a BPA CALL to the contractor.

4.2. Scheduling. The Service Member will be instructed to contact the Contractor directly for scheduling, once the BPA CALL is issued. The contractor shall not schedule any individual that is not listed on the BPA CALL. Appointments will be based on availability by the contractor, and the individuals identified per BPA CALL. Service Members must complete their vision examination within 60 days of issuance of the BPA CALL. If personnel are unable to meet this deadline, an exam will not be scheduled. The contractor shall report missed appointments to the Office of the State Surgeon at 614.336.6096.

4.3. Vision Examinations. The contractor will complete all components of the vision exam as outlined in Table 1.

4.3.1. Administrative Requirements. The contractor shall provide report of vision examination results using Form 1 – Vision Exam Results (Enclosure 1). Report must be signed by licensed optician. The contractor shall mail results to the following address within 14 calendar days of the physical examination date:

The Adjutant Generals Department Attn: Office of the State Surgeon 2825 West Dublin Granville Road Columbus, Ohio 43235

4.3.2. Instructions for completing Vision Exam Results Form

Blocks 1‐10. To be completed by the service member or unit.

Block 11 – Distance Vision. Record uncorrected, corrected, sphere, cylinder, and axis for each eye.

Block 12 – Refraction. Cycloplegic refraction required for Initial/Class I only. All others, see Table 1 Notes.

Block 13. Near Vision. Record right/left uncorrected, corrected and Add for each eye.

Block 14. Heterophoria. Requires Phorias, Cover‐uncover test (tropias) and Near Point Convergence.

Block 15. Accommodation.

Block 16. Color Vision. Must use PIP. (Scoring = plates missed/plates tested)

Block 17. Depth Perception. Annotate test conducted (Randot, Titmus or AFVT). Results listed as # arc sec. Ex. Randot 25 arc sec

Block 18. Field of Vision. Record finding for each eye. Ex. OD: NTC, OS: NTC.

Block 19. Night Vision. NIBH or annotate abnormalities.

Block 20. Intraocular Pressure. Greater than 4mmHg between eyes = Fail.

Block 21. Amsler Grid.

Block 22. Other Vision Testing/Notes. Record Corneal Topography results (if required). Record additional testing. Record special notes that do not fit into Blocks 11‐21.

Block 23. Print/type name of examiner.

Block 24. Record Date of Examination.

Block 25. Examiner signs.

TABLE 1

SUMMARY OF REQUIREMENTS FOR OHARNG VISION EXAMINATIONS

SPECIAL FORCES AVIATION OCCUPATIONAL

HEALTH FF

R E

Q U

IR

E

M E

N T

SFA

S

H A

L O

D

IV

E

Initial FD M

E (I)

Initial FD M

E

(II/III)

C om prehensive FD M

FD

H

S

C H

D O

D M

E R

B

C

- A

C

- B

C

- C

FIR

FIG

H

T E

R S

Red/Green Exam Y (5)

Y (5)

Y

(5) N N N N Y

(5) Y Y Y Y Y

Distant Vision Y Y Y Y Y Y Y Y Y Y Y Y Y

Near Vision Y Y Y Y Y Y Y Y Y Y Y Y Y

Color Vision Y Y Y Y Y Y N Y Y Y Y Y Y

Stereopsis/Depth Perception (Randot, Titmus, or AFVT)

N N N Y Y Y Y N Y Y Y Y Y

Phorias by AFVTA N N N Y Y Y N N N N N N N

Heterophorias N N N Y Y Y N N Y N N N N

Cover/Uncover Test (tropias) N N N Y Y N N N Y N N N

N

Near Point of Convergence N N N Y Y N N N Y Y Y Y

N

Visual Fields (confrontation) N N N Y Y N N N N Y Y Y

N

Night Vision Hx N N N Y Y N N N N N N N N

Refraction Cycloplegic N N N Y N N N N N N N N

N

Refractions Manifest Y (1)/(2)

Y (1)/(2)

Y (1)/(2) N Y

(3) Y (3)

Y

(3) N Y N N N

N

Interoccular Tension/Pressure N N N Y Y Y

(4) Y

(4) N N N N N

N

Ocular Motility & Binocularity (red lens test)

N N N N N N N N Y N N N N

Corneal Topography N N N Y N N N N N N N N N

Amsler Grid N N N N N N N N N Y (6)

Y (6)

Y (6)

N

Notes:

(1) Required if Distant Vision uncorrected is worse than 20/70 or Distant Vision corrected does not correct to 20/20 in each eye

(2) Near Vision must correct to 20/40 in better eye, if not, both eyes require refraction

(3) Required if uncorrected is worse than 20/20

(4) Required if examinee is age 40 and over

(5) Required if examinee failed Color Vision exam

(6) The OHARNG will provide a by name roster to the vendor

1. Last Name-First Name-Middle 2. Home Address 3. Phone Number 4. Email Address

5. Grade 6. Date of Birth 7. Age 8. Birth Sex 9. Unit of Assignment

10. Purpose of Examination

� SFAS � Initial FDME (I) � Tech A � HALO � Initial FDME (II/III) � Tech B � DIVE � Comp FDME � Tech C

� FDHS � Firefighter � Chapter 2

� DODMERB

11. Distance Vision

12. Refraction: MANIFEST CYCLO 13. Near Vision

Right Uncorrected 20/

Corrected to 20/ SPH: CYL: AXIS: Right

Corrected to 20/ ADD:

Left

Corrected to 20/ SPH: CYL: AXIS: Left

Corrected to 20/ ADD:

14. Heterophoria

ES

EX R.H. L.H. Prism D.V. Prism Conv CT NPR PD

15. Accomodation

16. Color Vision (Pass/Fail and Score) 17. Depth Perception (Pass/Fail and Score) Right

Left PIP Red/Green Color Dx. AFVT RANDOT/MCST

18. Field of Vision 19. Night Vision 20. Intraocular Pressure 21. Amsler Grid

O.D. O.S.

22. Other Vision Testing/Notes

23. Typed or Printed Name of Examiner

24. Date of Examination 25. Signature