W91242-17-R-0007_Att_1.pdf

PDF 104 KB Posted Apr 26, 2017

Attached to: PHA Events - NC Federal contract opportunity
Solicitation number: W91242-17-R-0007
Issued by: Department of the Army North Carolina Army National Guard

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Medical Event Request Forms

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File	Type	Posted
RFP_W91242-17-R-0007.pdf	PDF	Apr 26, 2017
RFP_W91242-17-R-0007_PPQ.docx	DOCX document	Apr 26, 2017

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Medical Numbers

G6PD DNA

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0001

CHARLOTTE 15 JULY 2017

4240 West Boulevard

Charlotte, NC 28208

15 JULY 2017 0730 15 JULY 2017 1700

180 25 25

18 5 180 25 10 10

0 18 18 18 YES YES YES

20 20 YES 40 20 30 YES

MOB EVENT

MOB Event

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0002

KURE BEACH 11-13 AUGUST 2017

122 River Front Road

Kure Beach NC 28449

August 11 2017 0730 August 13 2017 1700

450 50 40

10 5 225 50 10 10

0 45 45 20 YES YES NO

20 20 YES 90 20 50 YES

Annual Medical Readiness Event

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0003

MORRISVILLE 4 AUGUST 2016

2050 National Guard DR

Morrisville NC 27560

4 Aug 17 0800 4 Aug 17 1700

150 40 43

180 VALIDATION

Portable Med Portable Dental exams Mobile tx

10 5 180 40 20 20

0 18 18 10 YES YES YES

10 10 YES 36 20 18 YES

MOB EVENT VALIDATION

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0004

WINTERVILLE (MOB EVENT) 5 AUGUST 2016

3000 South Mill Street

Winterville NC 28590

AUGUST 5 2017 0730 AUGUST 5 20171700

163 20 15

163 Portable Med Portable Dental exams Mobile tx

5 1 81 20 5 5

0 16 16 16 YES NO NO

16 16 YES 32 20 16 YES

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0005

GASTONIA 6 AUGUST 2017

2100 ROBINWOOD

Gastonia NC 28054-5895

6 AUGUST 2017 0730 6 AUGUST 2017 1700

170 25 25

18 5 180 25 10 10

0 18 18 18 YES YES YES

20 20 YES 34 20 30 YES

MOB EVENT

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0006

HHC 30TH ABCT SRC 9 SEPTEMBER 2017

BLDG#3-1825 , MODULARITY DR,

FT BRAGG NC 28307

September 9 2017 0730 September 9 2017 1700

140 20 15

5 5 70 20 5 5

140 14 14 14 YES NO NO

14 14 YES 28 20 14 YES

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0007

FAYETTEVILLE 9-10 SEPTEMBER 2017

3555 Owen Drive

Fayetteville NC 28306

September 9 2017 0730 September 10 2017 1700

325 40 25

20 5 175 40 8 8

325 32 32 15 YES YES NO

32 32 YES 66 20 30 YES

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0008

NASHVILLE 9-10 SEPTEMBER 2017

1030 Eastern Avenue

Nashville NC 27856

September 9 2017 0730 September 10 2017 1700

300 40 25

10 5 150 40 8 8

300 30 30 15 YES YES NO

15 15 YES 60 20 30 YES

FLU HEPA HEPB TDAP

MRR VAR Percent Pano

OPTOMERTY

EKG

ENDO

For G1 MEDICAL use only

POC Email

Event Details

Phone Number

Event State: Event Zip:

Primary POC

HIV

NCARNG Medical Event Request Form

G1 Medical

Event Location

Brigade/MSC:

Battalion:

To:

Event Name:

Event Street Address:

Event City:

PREGNANCY TESTS LIPID PANEL

HEARING EXAMS SPRINT TESTS

Dental Treatment Hours:

LIVE DENCLASS

ORAL SUGURY

LIVE HRR

Data Entry: Additional Notes:

Participating Units/UICs:

Number of Females Over 40

Alternate POC

Phone Number

POC Email

Attending Day 1

Attending Day 3 Attending Day 2

Notes

Total Attending

Dental Numbers

Event Start Date/Time

Event Type:

Portable Medical Equipment Portable Dental Exams Mobile Dental Treatment

Event End Date/Time

CLIN 0009

Greensboro 16-17 September

110 Franklin BLVD

Greensboro NC 27401

September 16, 2016 0730 September 17, 2016 1700

301 30 20

AGR # 18

Portable Medical set up inside Armory, Portable Dental exams and mobile dental treatment

150 30 10 10

301 20 20 15 301 YES NO

20 20 YES 60 20 30 YES

CLIN 0001 CHARLOTTE 15 JULY 2017

CLIN 0002 KURE BEACH 11-13 AUGUST 2017

CLIN 0003 MORRISVILLE 4 AUGUST 2017

CLIN 0004 WINTERVILLE 5 AUGUST 2017

CLIN 0005 GASTONIA 6 AUGUST 2017

CLIN 0006 FT BRAGG 9 SEPTEMBER 2017

CLIN 0007 FAYETTEVILLE 9-10 SEPTEMBER 2017

CLIN 0008 NASHVILLE 9-10 SEPTEMBER 2017

CLIN 0009 GREENSBORO 16-17 SEPTEMBER 2017

File details come from the government source that posted it. Updated Nov 14, 2017.