PWS_-_Technician_Physical_Exams.docx

PERFORMANCE WORK STATEMENT

NEVADA ARMY NATIONAL GUARD OCCUPATIONAL HEALTH EXAMS

1. GENERAL

1.1 The Performance Work Statement (PWS) supports the Nevada Army National Guard (NVARNG) for Occupational Medical Surveillance Examination Program in accordance with the Occupation Safety and Health Association (OSHA) and other regulations. The anticipated total number of personnel to be examined is 150. Personnel will receive examinations at one of three NVARNG facilities (Las Vegas, Carson City or Reno) by means of a mobile examination unit.

2. PURPOSE

2.1. The purpose of the Occupational Medical Surveillance Examination Program is to provide job-related Occupational Health Examinations and Medical Surveillance Services to the NVARNG full-time support (FTS) and/or temporary personnel 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. Personnel included in these examinations are Federal Government Civil Service employees only.

2.2. The Government will 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 Physician(s) with experience in Occupational Health, supervision, all labor, tools, materials, equipment, and incidentals required to conduct the Occupational Health Examinations / Medical Surveillance Services for the NVARNG.

3. PROCEDURES and STANDARDS

3.1. 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 into 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.

3.2. 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.

3.3. Contractor shall ensure all clinical laboratory services are performed by a laboratory licensed through the U.S. Department of Health and Human Services (DHHS), Health Care Financing Administration pursuant to the terms of the Clinical Laboratories Improvement Act of 1967 (42 U.S.C. 263a) and the College of American Pathologies.

3.4. Contractor shall provide a Board eligible or Certified Occupational Medicine Physician to conduct job-related medical surveillance physical examinations and occupational health specialty examinations.

3.5. Contractor shall arrange for the opportunity to consult with the Occupational Health Nurse (OHN) of the NVARNG by telephone to coordinate or resolve issues that might arise before, during, and after the testing period.

3.6. Contractor shall perform a comprehensive review and evaluation within 30-days following the conclusion of testing. The Contracting Officer’s Representative (COR) will contact and schedule a follow-up review and evaluation meeting to discuss positive and negative aspects of testing.

3.7. Contractor will use documentation provided by NVARNG to conduct and document the physicals and is responsible to ensure all equipment and personnel are available to complete specific exams requirements.

3.8. Contractor will provide a Job Functional Analysis or Kraus-Weber that includes back strength and flexibility if requested. Note any pain or recommended lifting limitations if less than 50 lbs.

3.9. Contractor shall ensure audiogram must be certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC) or the equivalent military Defense Occupational and Environmental Health Readiness System-Hearing Conservation (DOEHRS-HC) training in accordance with 29 CFR 1910.95.

a. Hearing screenings will be conducted on employees designated by the OHN to include all workers exposed to occupational noise > 85 dBA or 140 dBA impact noise as part of their job duties.

b. All hearing tests will be entered into DOEHRS-HC by the contractor.

c. An orthoscopic exam will be conducted to ensure absence of injury and obstruction.

d. Test Only 500, 1000, 2000, 3000, 4000 and 6000.

e. Hearing aids must be removed.

f. Contractor must verify that worker has been noise free for at least 14 hours prior to screening.

g. All hearing screenings besides the baseline will be compared against the employee’s baseline to determine if there is a Significant Threshold Shift (STS) and retested immediately to verify results. Contractor will notify the Occupational Health Nurse within 10 days so that timely follow-up can be scheduled.

3.10. Contractor shall ensure Pulmonary Function Tests (PFTs) Performed by a licensed physician, Certified Pulmonary Function Technologist, or Registered Respiratory Therapist in accordance with 29 CFR 1910.1001. The estimated number of personnel to receive PFTs is approximately 15.

a. Screenings will only be conducted on employees designated by the OHN to include all those exposed to respiratory hazards that will require a respirator to mitigate hazards identified as above the action level.

b. Test will include as a minimum Forced Expiratory Volume in one second (FEV1), Forced Vital Capacity (FVC), comparison with recognized normal’s for the individual's height and weight, sex, race, age and a documented interpretation by a pulmonologist or certified Occupational Health physician.

c. Follow NIOSH and ATS-ERS standard requirements:

1. Continue testing individual when the patient is improving until improvement is <30ml.

2. Test results are acceptable with a minimum of three acceptable maneuvers that are free from a leak, obstructed mouthpiece, hesitation, false starts, cough, glottis closure, early termination, and have a good curve of at least 6 seconds duration.

3. Test results are reproducible in that they have the same result from the individual (two largest FVCs are within 0.150 L of each other and two largest FEV1's are within 0.150 L of each other) when the test is repeated several times. Testing is continued until criteria are met or trials are attempted, or the employee being tested cannot or should not continue.

4. If three (3) acceptable and two (2) repeatable tests cannot be obtained, the technician performing the PFT must document the reason the standard could not be met.

5. Always use measured height not reported height by the nearest half inch without Footwear.

6. Always indicate source of reference value on reports for adjusted predicted value

7. No smoking within 1 hour prior

8. No cold, flu or allergies within two weeks

9. No inhaler use prior to test that would still be in the patient’s system

d. Specifications regarding equipment guidelines and calibration, test administration, and test interpretation must meet applicable OSHA and ANSI standards. Supporting documentation will be provided to this office daily or annually depending on manufacturing guidelines of spirometer.

e. Respirator clearance documented and a copy given to employee at time of visit.

3.11. Contractor will provide quantitative fit testing in accordance with 29 CFR 1910.134 appendix A. The estimated number of personnel to receive fit testing is approximately ten (10).

a. The masks/respirator will be brought to the testing site by the individual employee who has one assigned to them for their utilization.

3.12. Contractor will ensure that vision screenings are in accordance with DA PAM 40-506 using multiphasic vision screening equipment to measure the following primary visual skills and will be documented on a form provided by NVARNG.

a. Visual acuity for distance and near.

b. Lateral phorias for distance and near.

c. Vertical phorias for distance and near.

d. Depth perception.

e. Color perception.

f. Peripheral vision.

3.13. Contractor shall ensure laboratory tests will be processed by certified clinical laboratories and performed by personnel certified under the American Society of Clinical Pathology. The supporting laboratory will provide employee instruction and equipment necessary for tests requiring special collection methods and/or containers. Document that employee has been counseled by examining provider about laboratory test results. Provide a copy of lab results to employee for their primary care physician. Tests include:

a. Blood Chemistries (serum) with H&H, BUN and Creatinine.

b. Liver Function to include AP and if abnormal include GGTP.

3.14. Contractor shall ensure a review of systems on physical examinations must be performed by a physician with emphasis on areas most likely to be affected by the employee's occupational exposures or desired certification.

3.15. Contractor shall ensure that chest X-rays will be performed by a certified X-ray technician. The interpretation and classification will be performed by a B-reader, or a board eligible or certified radiologist meeting the requirements of 29 CFR 1910.1001 Appendix E: The estimated number of personnel to receive chest X-rays are none, but services must be available if requested.

a. Chest X-rays are only performed for employees that have documented enrollment into an asbestos program or other medical surveillance program as required.

b. Chest X-ray will include posterior-anterior and left lateral view.

3.16. Contractor shall ensure instrumentation must meet or exceed appropriate performance standards, and accuracy must be verified in accordance with current Occupational Medicine Certification standards.

3.17. Contractor shall provide the COR with a Quality Assurance Medical Surveillance Plan listing the procedures or processes, which shall be utilized to meet the requirements discussed in the PWS.

4. REFERENCES

4.1. Title 29, Code of Federal Regulations, Part 1910: Occupational Safety and Health Standards.

4.2. Title 29, Code of Federal Regulations, Part 1960: Safety and Health Provisions for Federal Employees.

4.3. American National Standards Institute (ANSI) 288.6-1884, American National Standard for Respiratory Protection, Respirator Use, Physical Qualifications for Personnel.

4.4. Threshold Limit Values and Biological Exposure Indices (TLVs), American Conference of Governmental Industrial Hygienists (ACGIH), Cincinnati, Ohio.

4.5. Army Regulation 40-5, Preventive Medicine 25 May 2007

4.6. Department of Defense 6055.05M, Occupational Medical Surveillance Manual 2 May 2007

4.7. U.S. Department of Labor, Code of Federal Regulations 29 (CFR) 1910.120 (b) (5), (f), Medical Surveillance

4.8. Army Regulation 11-34, The Army Respiratory Protection Program 15 Feb 1990

4.9. Headquarters, Department of the Army Pamphlet (DA PAM) 40-501 Hearing Conservation 10 Dec 1998

4.10. Headquarters, Department of the Army Pamphlet (DA PAM) 40-506 Vision Conservation 15 Jul 2009

5. PERSONAL PROTECTIVE EQUIPMENT (PPE)

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

5.2. Contractor shall ensure each healthcare worker complies with the requirements of 29 CFR 1910.1030 Blood borne Pathogens Standard.

6. INFECTIOUS WASTE DISPOSAL

6.1. Disposal of all infectious waste shall be in accordance with local, state, and federal Regulation and disposed of by the contractor unless other accommodations have been coordinated in writing.

6.2. Contractor shall ensure puncture resistant sharps containers are readily accessible to healthcare workers and located in all treatment areas where sharps could potentially be used.

7. LOCATION

7.1. Contractor must provide services on the NVARNG facilities in both regions of Nevada:

a. Northern Nevada: Reno and Carson City

b. Southern Nevada: Las Vegas

7.2 Access to Federal Facilities and Personal Information:

a. Protection of Personally Identifiable Information (PII). The contractor shall protect all Personally Identifiable Information (PII) encountered in the performance of services in accordance with DFARS 224.103 and DoD 5400.11, Department of Defense Privacy Program, and DoD 5400.11-R. If a PII breach results from the contractor’s violation of the aforementioned policies, the contractor shall bear all notification costs, call-center support costs, and credit monitoring service costs for all individuals who’s PII has been compromised.

b. iWATCH Training. The contractor shall brief all personnel performing work under this contract on the local iWATCH program available on line at:

http://www.myarmyonesource.com/cmsresources/Army%20OneSource/Media/Videos/Family%20Programs%20and%20Services/iWatch_Program/iWATCH%2060_4streaming.wmv This training shall be completed within 30 calendar days of the contract award and within 30 days calendar days of new employees starting performance work under this contract, with the result reported to the Contracting Officer NLT 45 day after contract award or start date.

8. MEDICAL REPORTS AND RECORDKEEPING

8.1. Contractors shall immediately contact the Occupational Health Nurse by telephone at (775)887-7253 if results of medical surveillance screening(s), which are questionable and / or of critical significance and / or require follow-up. Contractor shall ensure that all results to include all diagnostic tests, graphs, charts, reports, questionnaires, waivers, employee consent forms, physical findings, and examination results are made available to the Occupational Health Nurse within 30 working days of completion of testing. Any electronic access to records must be in printable format suitable to be filed in the employee’s medical record. Mailed documentation will be sent to the address listed below and the contractor is responsible for all postage fees.

Nevada Army National Guard ATTN: To Be Determined 2460 Fairview Drive Carson City, NV 89701

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

8.3. Contractor shall ensure that each employee signs the Privacy Act Statement (DD Form 2005) during the registration process.

9. Summary Report:

The Contractor will provide a comprehensive report as follows:

9.1 Reports will be provided every six months directly to shops that were supported.

Addresses and a point of contact for each shop will be provided. Each report will include a summary of shops employees by name and the date and type of physical(s) performed and indicate qualified or not qualified for each type and expiration. Documentation of these qualifications with expirations will be provided as a certification card for each worker examined and copies of these cards will be included in the report. All information contained within the report must be sufficient for the supervisor to refer to during an inspection without violating HIPAA. A duplicate report will be sent to the Occupational Health Nurse via electronic format.

10. EXAMINATION SCHEDULING

10.1. The Government desires to consolidate as many examinations as possible at each site. Coordination of scheduling shall be a joint effort between the Occupational Health Nurse and the Contractor, a draft copy of the scheduled will be initiated by the Occupational Health Nurse and sent to the Contractor for review and any needed adjustments. Contractor will provide the Occupational Health Nurse the estimated time needed for each employee based on physical components required to ensure efficient use of scheduled time. Contractor will schedule mobile unit within 30 days before or after requested target date and will make every effort to accommodate the corresponding shops schedule. Scheduling of employees to be examined at clinic locations will be accommodated by the Contractor within 30 days for routine visits and 7 days for urgent.

10.2. In the event of a Contractor equipment failure, specific testing and / or parts of Examinations that are not completed during the testing period shall be completed at a scheduled time mutually convenient for the Contractor, Occupational Health Nurse and the Shops. Unfinished testing / examinations will be completed at no additional cost to the Government. The option to schedule physicals not completed due to equipment failure, through a local occupational medical facility shall be done at no cost to the Government. The Contractor shall be directly responsible to cover costs for completing these make-up screenings.

11. SERVICE DELIVERY SUMMARY (SDS)

11.1. The service delivery summary is designed to be a concise statement of key deliverables which are measured to determine the contractor's performance success or failure.

PERFORMANCE OBJECTIVE PERFORMANCE SCHEDULE

Insurance & Licensed and/or certified staff for all physicians and technicians, 100% of the time

Equipment Certification Instrumentation meets or exceed performance standards, 100% of the time

Occupational Exams Scheduled within contract timeframe and proper exam elements performed 100 % of the time

Infectious Waste Disposal All sharp instruments, blood, and urine is handled and disposed of in accordance with federal, state, and local regulations, 100% of the time

Medical Reports and Recordkeeping Completed records are accessible within agreed time frame and reports are submitted in a timely manner, 100% of the time

SPECIFICATIONS – Exams by job code. The following exams may also require additional tests based on data from Industrial Hygiene (IH) surveys from each work location. The following information on lab tubes may differ from actual lab practices and are provided as a reference only. Asbestos testing needed as potential exposures are identified. ACFT refers to aircraft.

TEST PANEL: 01

(Work Groups: 5400, 5800) Fuel Distribution Worker, Surface Maintenance Mechanic Estimated Number: 80

Corporate Consent: Yes. (To Occupational Health Nurse of Nevada Army National Guard.)

Fasting: Standard - As needed

Medical Release of Information : As Needed/Required

History: Confidential DD Form 2807-1 AUG 2011 Report of Medical History Questionnaire, to include respiratory history for P.P.E. (MASK) wearers.

Employee ID: Standard - Full Name, work site location and last 4 SSN (Ensure Name on all pages)

Noise Exposure/Ear Protection: Hearing Protection Instruction and Audiogram Hearing Test and Case History Form

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation Audiogram Hearing Health History and Test Form Respiratory History (If they wear PPE)

DD Form 2807 – 1,AUG 2011 Report of Medical History DD Form 2808. Oct 2005 Report of Medical Examination Benzene - Physician’s Examination of the Record (Lab Results)

Provider Information: Clinic Address, Phone Number (s), Exam Coordinator, Physician’s Signature with printed name and address under the signature line

Temperature & Respirations: Standard - Record results on Medical Examination Record

Audiometric: Test Only: 500, 1000, 2000, 3000, 4000, 6000 + Hz -Hearing Booth or Sound Proof Room Preferred

Blood Pressure: Standard - Right and Left Arm - Record results on Report of Medical Examination Record

Chest X-Ray: PA. (ILO Interpretation) Initiate ILO Form. Mandatory

Height/Weight: Standard - Record results on Report of Medical Examination Record.

MD Exam: Physician hands-on exam (EKG over age 50, under 50 determined by Physician)

Otoscopic Exam: Standard - Record results on Report of Medical Examination Record.

Quantitative Fit Testing: Client will bring his or her Mask for Fit Testing – Masks generally utilized are – 3M 6100 -Half Face, 3M 6200 - Half Face, 3M6300- Half Face, and 3M 7800 – Full Face Mask

Respirations: Standard - Record results on Report of Medical Examination Record

Resting Pulse Rate: Standard - Record results on Report of Medical Examination Record

Spirometry: Standard - Record results on Report of Medical Examination Record.

Urinalysis: Dipstick - Record results on Report of Medical Examination Record

Vision: Near and Far Acuity, color and vertical/lateral phorias - Record all results

LABORATORY SPECIMENS (Test Panel 01) Lab to be used:

One (1) Tiger Top Tube

Blood CBC, PSA if over age 40

One (1) Lavender Top Tube One (1) Blue Top Tube One (1) 10 ml Acid Washed Urine container Blood Lead/ZPP Blood Cadmium Benzene clearance

TEST PANEL: 02

(Work Groups: 4800, 5700, 6900, 6912) ACFT Survival Equip, Materials Handler, Tools & Parts Attend, Motor Vehicle Op Estimated number: 10

Corporate Consent: Yes. (To Occupational Health Nurse of Nevada Army National Guard.)

Fasting: Standard - As needed

Medical Release of Information : As Needed/Required

History: Confidential DD Form 2807 – 1 AUG 2011 Report of Medical History Questionnaire

Employee ID: Standard – Full name, work site location and last 4 SSN (Ensure Name on all pages)

Noise Exposure/Ear Protection: Hearing Protection Instruction and Audiogram Hearing Test and Case History Form

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation - Audiogram Hearing Health History and Test Form DD Form 2807 – 1,AUG 2011 Report of Medical History DD Form 2808. Oct 2005 Report of Medical Examination

Provider Information: Clinic Address, Phone Number(s), Name of Exam Coordinator, Physician’s Signature with printed name and address under the signature line

Temperature & Respirations: Standard - Record results on Medical Examination Record

Audiometric: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth or Sound Proof Room Preferred

Blood Pressure: Standard - Right and Left Arm - Record results on Report of Medical Examination Record

Chest X-Ray: N/A

Height/Weight: Standard - Record results on Report of Medical Examination Record

MD Exam: Physician hands-on exam (EKG over age 50, under 50 determined by Physician)

Otoscopic Exam: Standard - Record results on Report of Medical Examination Record

Respirations: Standard - Record results on Report of Medical Examination Record

Resting Pulse Rate: Standard - Record results on Report of Medical Examination Record

Spirometry: Standard - Record results on Report of Medical Examination Record

Urinalysis: Dipstick - Record results on Report of Medical Examination Record

Vision: Near and Far Acuity, color and vertical/lateral phorias - Record all results

Comparative Data: Accomplished by provider of services

LABORATORY SPECIMENS (Test Panel 02) Lab to be used:

One (1) Tiger Top Tube One (1) Lavender Top Tube Blood : CBC, PSA if over age 40

TEST PANEL: 03

(Work Groups: 8602, 4600, 8800, 3100) ACFT Mechanic, Wood Worker, ACFT Engine Mechanic Estimated number: 35

Corporate Consent: Yes. (To Occupational Health Nurse of Nevada Army National Guard.)

Fasting: Standard – As Needed

Medical Release of Information : As Needed/Required

History: Confidential DD Form 2807-1 AUG 2011 Report of Medical History Questionnaire, to include respiratory history for P.P.E. (MASK) wearers.

Employee ID: Standard – Full name, work site location and last 4 SSN (Ensure Name on all pages)

Noise Exposure/Ear Protection: Hearing Protection Instruction and Audiogram Hearing Test and Case History Form

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation Audiogram Hearing Health History and Test Form Respiratory History Questionnaire (If they wear PPE/Mask)

DD Form 2807 – 1,AUG 2011 Report of Medical History DD Form 2808 - Oct 2005 Report of Medical Examination

Provider Information: Clinic Address, Phone Number (s), Exam Coordinator, Physician’s Signature with printed name and address under the signature line

Temperature & Respirations: Standard Record results on Medical Examination Record

Audiometry: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth Preferred

Blood Pressure: Standard - Right and Left Arm - Record results on Report of Medical Examination Record

Chest X-Ray: PA. (ILO Interpretation.) Initiate ILO Form

Height/Weight: Standard - Record results on Report of Medical Examination Record

MD Exam: Physician hands-on exam (EKG over age 50, under 50 determined by Physician)

Otoscopic Exam: Standard - Record results on Report of Medical Examination Record

Quantitative Fit Testing: Client will bring his or her Mask for Fit Testing – Masks generally utilized are – 3M 6100 -Half Face, 3M 6200 - Half Face, 3M 6300- Half Face, and 3M 7800 – Full Face Mask

Respirations: Standard - Record results on Report of Medical Examination Record

Resting Pulse Rate: Standard- Record results on Report of Medical Examination Record

Spirometry: Standard - Record results on Report of Medical Examination Record

Urinalysis: Dipstick - Record results on Report of Medical Examination Record

Vision: Near and Far Acuity, color and vertical/lateral phorias - Record all results

LABORATORY SPECIMENS (Test Panel 03) Lab to be used:

One (1) Tiger Top Tube

Blood: CBC, PSA if over age 40

TEST PANEL: 04

(Work Groups: 2600, 2800, 3300, 6600) Target Sys. Repairer, Small Arms Repairer, Artillery Repairer, Electronics Mechanic, Electronic Measurement Equipment Mechanic

Estimated Number: 20

Corporate Consent: Yes. (To Occupational Health Nurse of Nevada Army National Guard.)

Fasting: Standard – As Needed

Medical Release of Information : As Needed/Required

History: Confidential DD Form 2807-1 AUG 2011 Report of Medical History

Employee ID: Standard – Full name, work site location and last 4 SSN (Ensure Name on all pages)

Noise Exposure/Ear Protection: Hearing Protection Instruction and Audiogram Hearing Test and Case History Form

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation - Audiogram Hearing Health History and Test Form DD Form 2807 – 1,AUG 2011 Report of Medical History DD Form 2808. Oct 2005 Report of Medical Examination

Provider Information: Clinic Address, Phone Number (s) , Name of Exam Coordinator, Physician’s Signature with printed name and address under the signature line

Temperature & Respirations: Standard - Record results on Medical Examination Record

Audiometry: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth Preferred

Blood Pressure: Standard - Right and Left Arm - Record results on Report of Medical Examination Record

Chest X-Ray: N/A or if Spirometry abnormal or if indicated by physician it should be accomplished

Height/Weight: Standard - Record results on Report of Medical Examination Record

MD Exam: Physician hands-on exam (EKG over age 50, under 50 determined by Physician)

Otoscopic Exam: Standard - Record results on Report of Medical Examination Record

Respirations: Standard - Record results on Report of Medical Examination Record

Resting Pulse Rate: Standard - Record results on Report of Medical Examination Record

Spirometry: Standard - Record results on Report of Medical Examination Record

Urinalysis: Dipstick - Record results on Report of Medical Examination Record

Vision: Near and Far Acuity, color and vertical/lateral phorias - Record all results

Comparative Data: Accomplished by provider of services

LABORATORY SPECIMENS (Test Panel 04) Lab to be used:

One (1) Tiger Top Tube

Blood: CBC, PSA if over age 40

TEST PANEL: 05

(Work Groups: 3400, 3700, 3800, 4100) Mobile Equipment Metal Mechanic, Allied Trades Helper, Paint Worker, Welder, Sheet Metal Mechanic, Machinist Estimated Number: 5

Corporate Consent: Yes. (To Occupational Health Nurse of Nevada Army National Guard.)

Fasting: Standard – As Needed

Medical Release of Information : As Needed/Required

History: Confidential DD Form 2807-1 AUG 2011 Report of Medical History Questionnaire to include respiratory history for P.P.E. (MASK) wearers.

Employee ID: Standard – Full name, work site location and last 4 SSN (Ensure Name on all pages)

Noise Exposure/Ear Protection: Hearing Protection Instruction and Audiogram Hearing Test and Case History Form

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation Audiogram Hearing Health History and Test Form Respiratory History Questionnaire (If they wear PPE/Mask)

DD Form 2807 – 1 AUG 2011 Report of Medical History DD Form 2808 - Oct 2005 Report of Medical Examination

Temperature & Respirations: Standard - Record results on Medical Examination Record

Audiometry: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth Preferred

Blood Pressure: Standard - Right and Left Arm - Record results on Report of Medical Examination Record

Chest X-Ray: PA. (ILO Interpretation.) Initiate ILO Form

Height/Weight: Standard - Record results on Report of Medical Examination Record

MD Exam: Physician hands-on exam (EKG over age 50, under 50 determined by Physician)

Otoscopic Exam: Standard - Record results on Report of Medical Examination Record

Quantitative Fit Testing: Client will bring his or her Mask for Fit Testing – Masks generally utilized are – 3M 6100 -Half Face, 3M 6200 - Half Face, 3M6300- Half Face, and 3M 7800 – Full Face Mask

Respirations: Standard - Record results on Report of Medical Examination Record

Resting Pulse Rate: Standard - Record results on Report of Medical Examination Record

Spirometry: Standard - Record results on Report of Medical Examination Record

Urinalysis: Dipstick - Record results on Report of Medical Examination Record

Vision: Near and Far Acuity, color and vertical/lateral phorias - Record all results

LABORATORY SPECIMENS (Test Panel 05) Lab to be used:

One (1) Tiger Top Tube

Blood: CBC, PSA - If over age 40

One (1) Lavender Top Tube One (1) Blue Top Tube One (1) 10 ml Acid Washed Urine container Blood Lead/ZPP Blood Cadmium Urine Chromium

Urine Chromium for PAINTERS and WELDERS ONLY

1.0 Insurance

A. Government Responsibilities:

The members of the Nevada Army National Guard, while engaged in official activities of the Nevada Military Department or when activated under Title 10 of the United States Code, are covered under the Military Claims Act and/or the Federal Tort Claims Act.

Therefore, any claims of liability against the Nevada Army National Guard or its members, for conduct occurring in their official scope of activity, will be processed for payment or denial under the MCA or FTCA.

B. Contractor Responsibilities:

1. Contractor shall maintain, at its own cost and expense, professional liability insurance covering Contractor as an entity and each of its provided physicians/employees and students against professional liability (malpractice) claims, in the minimum amount of one million dollars ($1,000,000.00) per occurrence and three million dollars ($3,000,000.00) aggregate. Evidence of such insurance shall be provided to Agency upon request. This provision shall in no way be considered a waiver of Contractor’s right to raise the defense of sovereign immunity under NRS 41.0305 to NRS 41.039, which right Contractor specifically reserves. Torts claims against physicians/employees are limited by NRS 41.035.

2. Contractor shall carry Workers’ Compensation and Employer’s Liability Insurance as required by NRS 616B.627 or provide proof that compliance with the provisions of Nevada Revised Statutes, Chapters 616A-D and all other related chapters, is not required.

3. Contractor shall maintain self-insurance to cover Contractor’s liability under NRS 41.

Coverage shall include liability arising out of bodily injury, wrongful death, and property damage.

2.0 Access

The Government agrees to provide Contractor and its insurer access and authority to investigate onsite and to obtain such information from Agency as may be required to defend Contractor and its officers or employees from claims or litigation arising from activities.

3.0 Liability

3.1 Agency shall be responsible for any liabilities, claims, losses, lawsuits, judgments, and/or expenses, including attorney fees arising either directly or indirectly from any act or failure to act by Agency or any of its staff or employees, which may occur during or which arise out of the performance of this Agreement, to the extent that the liability of the Agency is determined pursuant to the Federal Tort Claims Act, or Nevada state law, as appropriate.

3.2 To the extent limited in accordance with NRS 41.0305 to NRS 41.039, Contractor shall indemnify, defend, and hold harmless Agency, its governing board, officers, faculty, agents, and employees from and against any and all liabilities, claims, losses, lawsuits, judgments, and/or expenses, including attorney fees, arising either directly or indirectly from any act or failure to act by Institution, its officers or employees, which may occur during or which may arise out of the performance of this Agreement, and limited to the extent of the professional liability insurance limits set forth in paragraph 2.0 B.1 hereinabove. In accordance with NRS Chapter 41, Contractor will assert the defense of sovereign immunity as appropriate in all cases, including malpractice and indemnity actions. Claims against Contractor, its officers, and employees are limited by the monetary amount set forth in NRS Chapter 41.

3.3 In the event each of the parties is found to be at fault, then each shall bear its own costs and attorney’s fees and its proportionate share of the judgment or settlement based on its percentage of fault, as determined by appropriate federal or state law.

3.4 This Article shall continue beyond expiration of this Agreement.

4.0 Non-Discrimination and Compliance with Laws

4.1 The parties agree in this clinical program to comply with all the federal, state, local, and institutional laws, ordinances and rules applicable to Contractor, and specifically agree not to unlawfully discriminate against any individual on the basis of race, creed, color, sex, religion, age, disability, or national origin, and to comply with all anti-discriminatory laws and policies which Contractor promulgates and to which Contractor is subject.

4.2 The parties agree to comply with all state, federal, and local laws, including but not limited to the Family Educational Rights and Privacy Act of 1974 and all applicable state and federal laws pertaining to confidentiality of medical records.