W9128F19Q0079,_Ft._Randall_Medical_Surviellances.pdf

SEE ADDENDUM

(No Collect Calls)

W9128F19Q0079 24-Jun-2019

b. TELEPHONE NUMBER

402-995-2039

8. OFFER DUE DATE/LOCAL TIME

02:00 PM 28 Jun 2019

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 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.

W9128F9. ISSUED BY

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

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

LYNNE D REED

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

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

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

W59XQG90526450

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

U.S. ARMY CORPS OF ENGINEERS, OMAHA DIST

CONTRACTING OFFICE

1616 CAPITOL AVENUE

OMAHA NE 68102-4901

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 968810 16. ADMINISTERED BY

12. DISCOUNT TERMS11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

X SEE SCHEDULE

14. METHOD OF SOLICITATION

RFQ IFB RFPX

COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

TEL: 605-487-7845 X 3503 FAX: 605-487-7540

FAX:

TEL: SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$11,000,000

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 OF43

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.

Section SF 1449 - CONTINUATION SHEET

MEDICAL SURVEILLANCE GUIDANCE

DEPARTMENT OF THE ARMY

CORPS OF ENGINEERS,

OMAHA DISTRICT 1616

CAPITOL AVENUE

OMAHA NE 68102-4901

CENWO-SO 18

June 2019

MEMORANDUM FOR: Medical Provider, Project Medical Surveillance Coordinator SUBJECT: FY2019 Occupational Health / Medical Surveillance Guidance REFERENCE: OSHA, NIOSH, DOD, DA, EM

385-1-1, ER 385-40

Specific guidance with regard to tests and the processing of the paperwork for these examinations. It is most important that you are familiar with the regulations that govern the medical requirements and follow the guidelines specifically as to how the tests are administered. I have referenced some of the regulations, i.e., 29 CFR 1910.95 for audiograms, 29 CFR 1910.1000 for asbestos and 49 CFR 391.41 for DOT exams, ER 385-1-40.

1. All workup tests for the exam may be performed by an MD, DO, PA, nurse practitioner, or nurse), however, an Occupational Health Physician (MD or DO) shall sign the physician’s written opinion and medical clearances based on the results of the tests performed. The OHP (MD or DO) is the signatory authority for the exam.

2. Notify the District Occupational Health Manager if a provider does not have OHP on staff. The District Occupational Health Program Manager will then coordinate exam results with Federal Occupational Health OHP.

3. The project medical coordinator will provide the employee with a packet of health forms, with specific medical tests indicated. Please maintain a copy of all forms used for your records. Once the examination is completed, please forward a copy of these forms, plus all tests results to the address listed below. It is very important that current audiograms are compared with baseline audio for standard threshold shift and that we receive the comparison along with the medical test results.

U.S. Army Corps of Engineers, Omaha District ATTN: CENWO-SO (Jeffrey J.

Skrivanek), Suite 943 1616 Capitol Avenue

Omaha NE 68102-4970

4. Enclosed are the following documents:

a. APPENDIX A: FY2019 USACE Physical Exam/Tests/Labs Guidance

b. APPENDIX B: Draft Occupational Health Statement of Work for Occupational Health Physician Services.

b. Certificate of Medical Examination - Optional Form 178

i. Completed for all physical examinations

ii. MD/DO must sign and date Part C

c. U.S. Army Corps of Engineers – Medical Surveillance Management Program – Health History and Physical Examination Form (USACE 5).

i. Completed for all physical examinations

ii. OHP (MD/DO) must sign and date Part V, and provide appropriate clearance

iii. Please provide a copy of Part IV report to the employee.

This is the Employee’s Report and any recommendations with regard to personal health issues should be provided on this form.

d. DOT Medical Examination Report For Commercial Driver Fitness Determination (MCSA-5875)

e. USACE Crane Operator Medical Examiners Certificate

f. Authorization of Disclosure (FOH-AUD)

5. Please contact your identified U.S. Army Corps of Engineers

Project Occupational Health / Medical Surveillance Program Coordinator, or you may contact me at 402-995-2913 if you need any assistance regarding the Occupational Health / Medical Surveillance Program.

JEFFREY J. SKRIVANEK, CSP, MEng Chief, Safety & Occupational Health Occ. Health Program Manager (OHPM)

APPENDIX A:

SUBJECT: FY2019 USACE Occupational Health Physical and Medical Surveillance Exam/Tests/Labs Scope of Work/Guidance for Medical Providers

REFERENCE: ER-385-1-40, 29 CFR 1910, 29 CFR 1926, 49 CFR 391.41

1. Annual physicals exams, tests, and lab/profile work that should be included in the scope of work for Powerhouse and Technical Support employees who are participating in the Occupational Health / Medical Surveillance Program (MSP).

Attached are all tests that may be required for each employee. Guidance concerning tests is provided below in the Medical Guidance for Bidders.

2. Employees who meet the requirements as determined by regulations above will receive medical testing as determined by their exposures or job requirements. For further guidance, contact the Safety Office (Jeff Skrivanek) at 402-995-2913.

3. Blood work (Consists of the following):

a. Lipid Panel: (Triglycerides, Cholesterol, HDL, LDL)

b. Comprehensive Metabolic Panel: (Serum Glucose, Calcium, Blood Urea Nitrogen, Creatinine, Sodium, Potassium, Chloride, Carbon Dioxide, Serum Total Protein, Serum Total Albumin, Bilirubin Total/Direct, Alkaline Phosphate, Alanine Amino Transfer, Aspartate Amino Transfer)

c. Complete Blood Count: (DIFF/PLT)

4. Chest X-ray: Posterior/anterior (PA) chest x-ray is to be accomplished when initially placed in Occupational Health / Medical Surveillance Program and interpreted by a radiologist. Additional chest x-rays may be required as determined by physician and specific exposures that warrant a look at the lungs.

Chest x-rays are not to be accomplished routinely. When abnormalities are noted on a PA x-ray, a lateral x-ray should be taken. If the problem seems to be occupationally related, the cost will be borne by USACE. If not, the patient should be referred to his private physician. Clinic must consult USACE point of contact before any tests other than those requested are performed.

Chest X-ray (CXR) with B Reader: This is required for anyone who is a participant in the asbestos medical surveillance program. If the field clinic does not have the capability to conduct the b-reader, then the CXR film is to be sent to the U. S.

Army Corps of Engineers (ATTN: CENWO-SO) for acquiring that service in Omaha. CXR, PA & Lateral may be requested by the agency, the examining physician, or the Corps of Engineers. NOTE: We request that the CXR and interpretation results be sent to the USACE at the same time. Send CXR to U. S.

Army Corps of Engineers 1616 Capitol Ave, Omaha NE, 68102 (ATTN: CENWO-

SO). This is less confusing for our Health Unit when compiling data to accompany the film for obtaining the B-Reader.

a. USACE employees that are currently working with asbestos with potential exposure above the OSHA PEL shall receive a CXR and B-Read at the following intervals.

i. 0-10 years since first exposure, any age: 5 Years.

ii. 10+ years since first exposure, age 15-35: 5 Years

iii. 10+ years since first exposure, age 35-45: 2 Years

iv. 10+ years since first exposure, age 45+: Annually

b. There is no legal requirement for medical monitoring after an employee is no longer exposed. USACE employees who have had previous asbestos exposure shall be offered an equivalent to the annual exam every five years.

c. Asbestos counseling: OSHA requires any employee having any past exposure and is currently a smoker to be counseled regarding the dangers of smoking and asbestos.

5. Electrocardiogram (ECG or EKG): A record of the electric potentials associated with the electric currents that traverse the heart that can be used to diagnose heart disease. The Standard 12-lead electrocardiogram contains three limb leads (I, II, and III), three augmented unipolar leads (aVr, aV1, and aVf) and six transverse precordial limb leads (V1-V6). Precordial electrode placement (V leads) must be consistent and patient position must be flat on the back. Technicians administering the ECG/EKG must be adequately trained in the procedure and all ECGs must be read by a physician, questionable ECGs are to be read by a specialist in internal medicine or a cardiologist. The physician reading the ECG must be familiar with the patient’s past history and physical examination results. Frequency of Electrocardiogram (EKG): (Routine w/Interpretation & Report):

a. An ECG/EKG baseline shall be accomplished when initially placed into the

Occupational Health / Medical Surveillance Program. ECG/EKG shall be accomplished at the following intervals:

i. Age 18-50: 5 Years

ii. Age 50+: 2 Years

iii. Age 40+ With 2 or More Risk Factors for Coronary Heart Disease: 2 Years. This authority is given to the medical provider.

6. Pulmonary Function Test (PFT): Spirometry measurement of both force vital capacity (FVC) and time force expiratory volume (FEV 1.0) performed a minimum of

3 times (all three times must be shown in tests results) over a period of several minutes, looking for reproducibility and consistency as well as maximum effort. The corrected reading is to be compared (using Knudson Tables for comparison) with expected values for the person's age, sex, height, and race. Technicians or nurses performing PFT must be properly trained and/or have attended a NIOSH approved course in pulmonary function testing. Daily calibration checks must be performed.

The fact that the calibration check was performed must be recorded on spirometry report form.

a. PFT for Asbestos Surveillance Program: All employees enrolled in the

Asbestos Surveillance Program will receive an annual Pulmonary Test.

Asbestos (REF: 29 CFR 1910.1001) Asbestos: the PEL for asbestos (all asbestiform minerals) is measured for fibers greater than 5 micrometers in length. The PEL is 0.1 fibers per cc. Mandatory medical questionnaires applicable to surveillance of asbestos exposed persons are published in Appendix D of the OSHA asbestos standard 29 CFR 1910.1001.

b. PFT for Respirator Users: All respirator users shall receive a pre-placement

PFT to gain a respirator medical clearance. The medical provider complete the medical questionnaire and examination as required by OSHA 1910.134.

The medical provider must identify respirator type, activity level, limitation, and clearance expiration not to exceed 2 years. Follow-on PFTs will be given to the authority of the medical provider depending on employee risk factors. Medical provider shall annotate respirator clearance on USACE 5 form page 9.

c. PFT for Welders: All ARC/TIG/MIG/Oxy Acetylene welders shall receive a pre-placement PFT. All welders require an annual PFT.

d.

7. Urinalysis: Includes a quantitative evaluation for the presence of protein, glucose, ketones and blood, determination of pH, specific gravity, and a microscopic examination of the sediment. UA is part of the standard examination and a requirement for all CDL Exams.

8. Visual Screening: Perform test with and without glasses. Includes tests for right eye individually, left eye individually, both eyes together for both near and far acuity, peripheral vision, depth perception, muscle balance, and color discrimination.

Provide visual screening to meet requirements DOT (CDL) and USACE Crane Operator.

9. Audiograms: Employees that meet criteria for inclusion in the Hearing Conservation

Program shall receive a baseline audiogram and annual audiograms in accordance with ER 385-1-89. Personnel who perform or interpret audiometric tests must either by an audiologist, otolaryngologists, or physician trained in audiometric testing and interpretation, diagnosis of hearing disorders, exposure assessment and determination of work related hearing loss. Audiometric test equipment must meet the specification of and be maintained and used in accordance with ANSI S3.6- 1996. Audiometer calibrations shall provide for daily and function tests. Annual acoustical calibration shall be checked acoustically, at least annually and in tolerances of the ASSA S3-1996. Audiometer test room background noise levels shall not have background sound pressure levels at the following values (500Hz- 40dB, 10Hz-40dB, 2000Hz-47dB, 4000Hz-57dB, 8000Hz-62dB). Each employee’s annual audiogram shall be compared to the employee’s baseline audiogram.

a. Baseline Audiogram: The baseline shall be performed on any newly hired individuals who will be enrolled in the hearing conservation program, have the potential to enter a noise hazardous area more than eight hours a week or exposed to an ototoxin. The baseline shall be preceded by a period of at least 14 hours away from workplace noise, and instructed to avoid loud noises during off duty hours prior to taking audiogram.

b. Annual Audiogram: An annual audiogram shall be provided to employees who are enrolled in the hearing conservation program in accordance with ER 385-1-89.

c. Repeat Audiograms: If an audiogram indicates a Significant Threshold Shift

(STS) the employee will receive a second audiogram as soon as possible and within 30 days. The purpose of the second audiogram is to determine if the STS is temporary or permanent. If the second audiogram does not confirm the loss or gain from the first audiogram, the employee does not require any further audiograms until the periodic audiogram. If the second audiogram confirms a decrease in hearing as a STS, then the employee shall receive a third audiogram with 30 days of the annual audiogram. The third audiogram will include clinical audiological evaluation or otological examination. The purpose of this exam and audiogram is to determine if the STS is permanent and/or work related, the effectiveness of the type of hearing protection being used by the employee, and if the employee should be allowed to return to work in hazardous noise. A revised reference audiogram shall be established using either the second or third follow-up tests.

10. DOT (CDL) Medical Exam: DOT Certification Examinations are required every 2 years for all employees where a DOT certificate is required to perform their work with the Corps. The exam shall be in accordance with 49 CFR 391.41. The commercial driver’s license (CDL) must be a requirement outlined in the employee’s position description. Unless the CDL is listed in the position description, the CDL exam WILL NOT be provided. Urinalysis Test is performed for all employees in the MSP getting a comprehensive exam (a person receiving only an audiogram would not get this test). Vision Exam. Vision screening with & without glasses must be performed. DOT examinations are required every other year. Employees should wear their newest prescription glasses or contact lenses for the vision screening. If the exam indicates that a new prescription is needed, the employee is responsible for obtaining a new prescription from an optometrist or ophthalmologist. Medical provider shall complete MCSA5875 “Medical Examination Report Form & Medical Examiners Certificate” and annotate CDL clearance on USACE 5 form page 9.

11. Crane Operator Physical Exam: Examinations are performed every 2 years.

Medical providers shall complete “USACE Crane Operator Medical Certificate” form (enclosure 5), and annotate crane operate clearance on USACE 5 form page 9.

Minimum requirements are history and physical, vision screening (20/30 snellen in one eye and 20/50 in the other without corrective lenses, normal depth perception and field of vision, ability to distinguish colors) audiometry (adequate hearing with or without hearing aid), sufficient strength / endurance / agility / coordination / manual dexterity / speed f reaction to meet the demands of the equipment, and no tendencies to dizziness or similar undesirable characteristics.

12. Hexavalent Chromium Examination: This exam in specifically for employee exposed to hexavalent chromium fumes produces from welding, arcing, grinding operations on stainless steel alloy. Medical and work history, with emphasis on:

past, present, and anticipated future exposure to chromium (VI); any history of respiratory system dysfunction; any history of asthma, dermatitis, skin ulceration, or nasal septum perforation; and smoking status history. Coordinate first with CENWO-SO before scheduling with clinic.

13. Heavy Metals Blood/Urine Tests: Welders shall receive a pre placement heavy metals blood/urine test (lead, magnesium, cadmium, arsenic, and chromium. The blood and urine tests should only be completed annually if sampling indicates an over exposure to hazard more than 30 days a year. Coordinate first with CENWO- SO before scheduling with clinic.

14. Diphtheria Tetanus Booster (Td): Required every 10 years for occupational risk exposures.

15. Hepatitis A: For employees whose job duties bring them into contact with raw sewage or other potentially infectious materials at or above the PEL. Preventive treatment of Hepatitis A involves a series of two injections over a period of six months. For adults, a small amount of vaccine fluid is injected into the army muscle initially, and is followed by a booster does six months after the first injection.

Coordinate first with CENWO-SO before scheduling with clinic.

16. Hepatitis B: For employees whose job duties involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues or a potential for spills or splashes. Vaccinations consist of 3 doses & booster. Initial Dose, Dose 2 (1 month after Dose 1), Dose 3 (6 months after Dose 1). Coordinate first with CENWO-SO before scheduling with clinic.

APPENDIX B:

Occupational Health Statement of Work Occupational Health Physician Services

Scope of Work

1.0 General Information

1.1 Scope of Work. The contractor shall provide periodic occupational health/medical surveillance physicals for the Fort Randall Project employees not to exceed 35 employees, as defined in this Performance Work Statement. Sample forms and certificates will be provided as separate attachments. All physicals and blood work will be performed at the contractor’s facility. All workup tests for the exam may be performed by an MD, DO, PA, Nurse Practitioner, or Nurse; however, an MD or DO shall sign the physician’s written opinion based on the tests performed. The MD or DO is the signatory authority for the exam.

1.1.1 Periodic physical exams, tests, and lab/profile work is required for all Fort Randall Project employees who meet the following requirements as determined by regulations EM 385-1-1, DR 385-1-1, 29 CFR 1910, 29 CFR 1926, 49 CFR 391.41(not all inclusive) due to their exposures or job requirements. All tests that may be required and test guidance for each employee are provided in this PWS. For further guidance, contact the Safety and Occupational Health Office (Jeffrey Skrivanek) at 402-995-2913. An Exposure Assessment Form will be completed each time an exam is requested for an employee.

1.1.2 Contractor shall perform services as requested; Provider serves as Medical Officer, giving guidance in form of written protocols for medical services; Provider shall provide preventive services within the competence of the professional staff; Provide health education to encourage employees to maintain personal health; and Provide specific disease screening examination and immunizations, as the department or agency head determines to be necessary.

1.2 Description of Medical Care.

1.2.1 Contractor shall provide the “hands-on” physicals for Government employees. Review of the examination and test results with the employee after the examination will be done by the physician. Referrals are made to the person's primary care physician. The types of physical examinations are as follows:

1.2.2 Specific medical surveillance examination based on work related exposures.

1.2.3 Medical examination to determine if an employee meets the qualification.

1.2.4 Pre-employment examination.

1.2.5 Medical examinations to determine if an employee is able to return to work following an injury.

1.2.6 Other examinations as necessary.

1.2.7 General physical assessment to include:

1.2.8 A review of the medical history;

1.2.9 An Evaluation of eyes, nose, mouth, ears, thyroid, heart, lungs, abdomen, reflexes, generalized skin condition, circulation, spine, back, and hernias;

1.2.10 A review with the employee the results of the exam and medical tests;

1.2.11 A review of the following types of medical tests: laboratory work to include CBC, PSA & TSH and specific tests based on the work place exposures, urinalysis, vision screening, electrocardiogram, audiogram, periodic chest X-rays, pulmonary function tests, and specific toxicological tests based on work exposure.

1.2.12 Any health education as having been identified in the medical tests.

1.3 Quality Control

1.3.1 The contractor shall designate, in writing, an employee who shall serve as the contact for matters involving quality and performance or nonperformance of the required work.

The employee (s) shall be qualified and fully competent with full authority to act for, and on behalf of, the contractor as necessary to insure that the required work is performed in accordance with the specifications and standards contained herein. The contractor shall furnish the above written designation to the Contracting Officer’s Representative/Project Medical Surveillance Program Coordinator at the project before work begins. The contractor shall include the name(s), addresses, and telephone number(s) of the responsible individual(s).

1.3.2 The Contracting Officer reserves the right to disapprove any individual whom he considers to be incompetent to perform the work required. Such disapproval’s will be given to the contractor by written notice.

1.4 Quality Assurance

1.4.1 Quality Assurance Surveillance Plan. A Quality Assurance Surveillance Plan will be used during the life of the contract to ensure that the Contractor is performing the services required by this PWS in an acceptable manner. The Government develops the QASP and the Project Office administers the Plan through Quality Assurance Evaluators (QAE)s.

1.4.2 The government has the right to inspect all reports/results called for by the contract, to the extent practicable.

1.4.3 If any of the services do not conform to contract requirements, the government may require the contractor to perform the services in conformity with contract requirements and at no increase in cost. If the contract requirements are not met after a second attempt the government may (1) require the contractor to take necessary action to ensure that future performance conforms to contract requirements and (2) reduce the contract price to reflect the reduced value of the services performed.

1.4.4 If the contractor fails to promptly perform the services again or to take the necessary action to ensure future performance is in conformity with the contract requirements, the government may (1) by contract, or otherwise, perform the services and charge to the contractor any cost incurred by the government that is directly related to the performance of such service or (2) terminate the contract in whole or in part.

1.4.5 As a quality assurance procedure, the provider should expect that the records of performance will be reviewed by a Board Certified Occupational Health Physician representing the USACE. This review will be completed as part of the contract quality assurance at any time during the contract.

1.5 Pre-Work Meeting. Prior to commencing any activities, the contractor shall arrange a

Pre-work Meeting with the COR/Project Medical Surveillance Program Coordinator.

The meeting shall discuss the work to be performed, scheduling of tests, and required forms/documents.

1.6 Period of Performance: The Period of Performance shall be one Base Year of 12 months and four (4) 12-month option years.

1.7 Security Requirements. All Contractor and all associated sub-contractors employees shall comply with applicable Health Insurance Portability and Accountability Act and Protected Health Information requirements. The performance of this contract will not require access to a government facility or property therefore no background checks are required for this contract.

2.0 Definitions. The following definitions and descriptions apply wherever the word, phrase, or acronym is used in this performance work statement.

Acceptable Level of Performance (ALP): The maximum percent defective, the maximum number of defects per hundred units, or the number of defects in a lot that can be considered satisfactory on the average. The allowable leeway or variance from a standard before the government will reject the specific service.

Contracting Officer’s Representative (COR): means an individual designated and authorized in writing by the Contracting Officer to perform specific technical or administrative functions.

Daily Duties: To be performed each day facilities are serviced.

Performance-Based Contract (FAR 2.101): Structuring all aspects of an acquisition around the purpose of the work to be performed with the contract requirements set forth in clear, specific, and objective terms with measurable outcomes as opposed to either the manner by which the work is to be performed or broad and imprecise.

Performance Requirements Summary (PRS): The PRS shows contract requirements, the component requirements related to each contract requirement, the price of each work requirement as a percentage of the associated contract requirement (Fixed Price Contracts), the standard of performance, and the acceptable level of performance (ALP) for each work requirement.

Quality Assurance Surveillance Plan (QASP): An organized written document used by the Government for quality assurance surveillance. Document contains sampling/evaluation guides, checklists, and the performance requirements summary

(PRS).

3.0 Specific Requirements. The contractor shall provide 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 52.237-74

– Indemnification and Medical Liability Insurance, including the maintenance of medical liability insurance.

3.1. The 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.

3.2. 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.

3.3. Contractor shall ensure a qualified medical doctor licensed within in the respective state, have been professionally employed in the Practice of Medicine for a minimum of five (5) years and be knowledgeable of regulations and resources relating to occupational medicine such as OSHA, NIOSH, DoD, DA and Occupational Medicine Practice Guidelines (ACOEM).

3.4 The project medical coordinator will provide the employee with a packet of health forms, with specific medical tests indicated. The contractor shall maintain a copy of all forms used for their records. Once the examination is completed, the contractor shall forward a copy of all forms, plus all tests results to the address listed below. Note: It is very important that current audiograms are compared with baseline audio for standard threshold shift and that the government receives the comparison along with the medical test results.

U.S. Army Corps of Engineers (USACE), Omaha District ATTN: CENWO-SO (Jeffrey J. Skrivanek), Suite 943 1616 Capitol Avenue Omaha NE 68102-4970

3.5. The contractor shall perform the following: The Government expects the following tests to be performed, which may be required, in addition to the hands-on physical for each employee.

3.5.1 Blood work (Consists of the following):

a. Lipid Panel: (Triglycerides, Cholesterol, HDL, LDL)

b. Comprehensive Metabolic Panel: (Serum Glucose, Calcium, Blood Urea Nitrogen, Creatinine, Sodium, Potassium, Chloride, Carbon Dioxide, Serum Total Protein, Serum Total Albumin, Bilirubin Total/Direct, Alkaline Phosphate, Alanine Amino Transfer, Aspartate Amino Transfer)

c. Complete Blood Count: (DIFF/PLT)

3.5.2 Chest X-ray: Posterior/anterior (PA) chest x-ray is to be accomplished when initially placed in Occupational Health / Medical Surveillance Program and interpreted by a radiologist. Additional chest x-rays may be required as determined by physician and specific exposures that warrant a look at the lungs. Chest x-rays are not to be accomplished routinely. When abnormalities are noted on a PA x-ray, a lateral x-ray should be taken. If the problem seems to be occupationally related, the cost will be borne by USACE. If not, the patient should be referred to his private physician. Clinic must consult USACE point of contact before any tests other than those requested are performed.

3.5.3 Chest X-ray (CXR) with B Reader: This is required for anyone who is a participant in the asbestos medical surveillance program. If the field clinic does not have the capability to conduct the b-reader, then the CXR film is to be sent to the U.S. Army Corps of Engineers (ATTN: CENWO-SO) for acquiring that service in Omaha. CXR, PA & Lateral may be requested by the agency, the examining physician, or the Corps of Engineers. NOTE: We request that the CXR and interpretation results be sent to the USACE at the same time. Send CXR to U. S.

Army Corps of Engineers 1616 Capitol Ave, Omaha NE, 68102 (ATTN: CENWO- SO). This is less confusing for our Health Unit when compiling data to accompany the film for obtaining the B-Reader.

d. USACE employees that are currently working with asbestos with potential exposure above the OSHA PEL shall receive a CXR and B-Read at the following intervals.

i. 0-10 years since first exposure, any age: 5 Years.

ii. 10+ years since first exposure, age 15-35: 5 Years

iii. 10+ years since first exposure, age 35-45: 2 Years

iv. 10+ years since first exposure, age 45+: Annually

e. There is no legal requirement for medical monitoring after an employee is no longer exposed. USACE employees who have had previous asbestos exposure shall be offered an equivalent to the annual exam every five years.

f. Asbestos counseling: OSHA requires any employee having any past exposure and is currently a smoker to be counseled regarding the dangers of smoking and asbestos.

3.5.4 Electrocardiogram (ECG or EKG): A record of the electric potentials associated with the electric currents that traverse the heart that can be used to diagnose heart disease. The Standard 12-lead electrocardiogram contains three limb leads (I, II, and III), three augmented unipolar leads (aVr, aV1, and aVf) and six transverse precordial limb leads (V1-V6). Precordial electrode placement (V leads) must be consistent and patient position must be flat on the back. Technicians administering the ECG/EKG must be adequately trained in the procedure and all ECGs must be read by a physician, questionable ECGs are to be read by a specialist in internal medicine or a cardiologist. The physician reading the ECG must be familiar with the patient’s past history and physical examination results. Frequency of Electrocardiogram (EKG):

(Routine w/Interpretation & Report):

g. An ECG/EKG baseline shall be accomplished when initially placed into the Occupational Health / Medical Surveillance Program. ECG/EKG shall be accomplished at the following intervals:

i. Age 18-50: 5 Years

ii. Age 50+: 2 Years

iii. Age 40+ With 2 or More Risk Factors for Coronary Heart Disease: 2 Years. This authority is given to the medical provider.

3.5.5 Pulmonary Function Test (PFT): Spirometry measurement of both force vital capacity (FVC) and time force expiratory volume (FEV 1.0) performed a minimum of 3 times (all three times must be shown in tests results) over a period of several minutes, looking for reproducibility and consistency as well as maximum effort. The corrected reading is to be compared (using Knudson Tables for comparison) with expected values for the person's age, sex, height, and race. Technicians or nurses performing PFT must be properly trained and/or have attended a NIOSH approved course in pulmonary function testing. Daily calibration checks must be performed. The fact that the calibration check was performed must be recorded on spirometry report form.

h. PFT for Asbestos Surveillance Program: All employees enrolled in the Asbestos Surveillance Program will receive an annual Pulmonary Test. Asbestos (REF: 29 CFR 1910.1001) Asbestos: the PEL for asbestos (all asbestiform minerals) is measured for fibers greater than 5 micrometers in length. The PEL is 0.1 fibers per

cc. Mandatory medical questionnaires applicable to surveillance of asbestos exposed persons are published in Appendix D of the OSHA asbestos standard 29

CFR 1910.1001.

i. PFT for Respirator Users: All respirator users shall receive a pre-placement PFT to gain a respirator medical clearance. The medical provider complete the medical questionnaire and examination as required by OSHA 1910.134. The medical provider must identify respirator type, activity level, limitation, and clearance expiration not to exceed 2 years. Follow-on PFTs will be given to the authority of the medical provider depending on employee risk factors. Medical provider shall annotate respirator clearance on USACE 5 form page 9.

j. PFT for Welders: All ARC/TIG/MIG/Oxy Acetylene welders shall receive a pre-placement PFT. All welders require an annual PFT.

k.

3.5.6 Urinalysis: Includes a quantitative evaluation for the presence of protein, glucose, ketones and blood, determination of pH, specific gravity, and a microscopic examination of the sediment. UA is part of the standard examination and a requirement for all CDL Exams.

3.5.7 Visual Screening: Perform test with and without glasses. Includes tests for right eye individually, left eye individually, both eyes together for both near and far acuity, peripheral vision, depth perception, muscle balance, and color discrimination. Provide visual screening to meet requirements DOT (CDL) and USACE Crane Operator.

3.5.8 Audiograms: Employees that meet criteria for inclusion in the Hearing Conservation Program shall receive a baseline audiogram and annual audiograms in accordance with ER 385-1-89. Personnel who perform or interpret audiometric tests must either by an audiologist, otolaryngologists, or physician trained in audiometric testing and interpretation, diagnosis of hearing disorders, exposure assessment and determination of work related hearing loss. Audiometric test equipment must meet the specification of and be maintained and used in accordance with ANSI S3.6-1996.

Audiometer calibrations shall provide for daily and function tests. Annual acoustical calibration shall be checked acoustically, at least annually and in tolerances of the ASSA S3-1996. Audiometer test room background noise levels shall not have background sound pressure levels at the following values (500Hz-40dB, 10Hz-40dB, 2000Hz-47dB, 4000Hz-57dB, 8000Hz-62dB). Each employee’s annual audiogram shall be compared to the employee’s baseline audiogram.

l. Baseline Audiogram: The baseline shall be performed on any newly hired individuals who will be enrolled in the hearing conservation program, have the potential to enter a noise hazardous area more than eight hours a week or exposed to an ototoxin. The baseline shall be preceded by a period of at least 14 hours away from workplace noise, and instructed to avoid loud noises during off duty hours prior to taking audiogram.

m. Annual Audiogram: An annual audiogram shall be provided to employees who are enrolled in the hearing conservation program in accordance with ER 385-1-89.

n. Repeat Audiograms: If an audiogram indicates a Significant Threshold Shift (STS) the employee will receive a second audiogram as soon as possible and within 30 days.

The purpose of the second audiogram is to determine if the STS is temporary or permanent. If the second audiogram does not confirm the loss or gain from the first audiogram, the employee does not require any further audiograms until the periodic audiogram. If the second audiogram confirms a decrease in hearing as a STS, then the employee shall receive a third audiogram with 30 days of the annual audiogram.

The third audiogram will include clinical audiological evaluation or otological examination. The purpose of this exam and audiogram is to determine if the STS is permanent and/or work related, the effectiveness of the type of hearing protection being used by the employee, and if the employee should be allowed to return to work in hazardous noise. A revised reference audiogram shall be established using either the second or third follow-up tests.

3.5.9 DOT (CDL) Medical Exam: DOT Certification Examinations are required every 2 years for all employees where a DOT certificate is required to perform their work with the Corps. The exam shall be in accordance with 49 CFR 391.41. The commercial driver’s license (CDL) must be a requirement outlined in the employee’s position description.

Unless the CDL is listed in the position description, the CDL exam WILL NOT be provided. Urinalysis Test is performed for all employees in the MSP getting a comprehensive exam (a person receiving only an audiogram would not get this test).

Vision Exam. Vision screening with & without glasses must be performed. DOT examinations are required every other year. Employees should wear their newest prescription glasses or contact lenses for the vision screening. If the exam indicates that a new prescription is needed, the employee is responsible for obtaining a new prescription from an optometrist or ophthalmologist. Medical provider shall complete

MCSA5875 “Medical Examination Report Form & Medical Examiners Certificate” and annotate CDL clearance on USACE 5 form page 9.

3.5.10 Crane Operator Physical Exam: Examinations are performed every 2 years.

Medical providers shall complete “USACE Crane Operator Medical Certificate” form (enclosure 5), and annotate crane operate clearance on USACE 5 form page 9.

Minimum requirements are history and physical, vision screening (20/30 snellen in one eye and 20/50 in the other without corrective lenses, normal depth perception and field of vision, ability to distinguish colors) audiometry (adequate hearing with or without hearing aid), sufficient strength / endurance / agility / coordination / manual dexterity / speed of reaction to meet the demands of the equipment, and no tendencies to dizziness or similar undesirable characteristics.

3.5.11 Hexavalent Chromium Examination: This exam is specifically for employee exposed to hexavalent chromium fumes produces from welding, arcing, grinding operations on stainless steel alloy. Medical and work history, with emphasis on: past, present, and anticipated future exposure to chromium (VI); any history of respiratory system dysfunction; any history of asthma, dermatitis, skin ulceration, or nasal septum perforation; and smoking status history. Coordinate first with CENWO-SO before scheduling with clinic.

3.5.12 Heavy Metals Blood/Urine Tests: Welders shall receive a pre placement heavy metals blood/urine test (lead, magnesium, cadmium, arsenic, and chromium). The blood and urine tests should only be completed annually if sampling indicates an over exposure to hazard more than 30 days a year. Coordinate first with CENWO-SO before scheduling with clinic.

3.5.13 Diphtheria Tetanus Booster (Td): Required every 10 years for occupational risk exposures.

3.5.14 Hepatitis A: For employees whose job duties bring them into contact with raw sewage or other potentially infectious materials at or above the PEL. Preventive treatment of Hepatitis A involves a series of two injections over a period of six months.

For adults, a small amount of vaccine fluid is injected into the army muscle initially, and is followed by a booster does six months after the first injection. Coordinate first with CENWO-SO before scheduling with clinic.

3.5.15 Hepatitis B: For employees whose job duties involve an inherent potential for mucous membrane or skin contact with blood, body fluids, or tissues or a potential for spills or splashes. Vaccinations consist of 3 doses & booster. Initial Dose, Dose 2 (1 month after Dose 1), Dose 3 (6 months after Dose 1). Coordinate first with CENWO- SO before scheduling with clinic.

W9128F19Q0079

4.0 Performance Requirements Summary. The Contractor service requirements are summarized into performance objectives that relate directly to mission essential items.

The performance threshold briefly describes the minimum acceptable levels of service required for each requirement. These thresholds are critical to mission success.

Performance Objective

Standard Performance Threshold

Method of Surveillance

PRS #1.

The contractor shall perform all tests when requested and provide results, as stated in this performance work statement.

The contractor shall provide all test results on 100% of the personnel undergoing OSHA physicals.

0% failure to perform tests and provide test results for OSHA physicals to the satisfaction of the government.

Periodic Inspection – COR will ensure all tests are conducted and reports are received.

BID SHEET

Fort Randall Medical Surveillance Sol: W9128F19Q0079

2019 Base Yr

2020 Option Yr #1

2021 Option Yr #2

2022 Option Yr #3

2022 Option Yr #4

Test No.

of

Test s

Cost Per Test

Total s

Cost Per Test

Totals Cost Per Test

Totals Cost Per Test

Total s

Cost Per Test

Total s

History & Physical

Audiometry 28

Visual Screening 28

Urinalysis (UA) 28

Pulmonary Function Test

(PFT)

Blood Work 24

Heavy Metals Blood Urine Test

Electrocardiogra m (EKG)

Chest X-Ray 0

Chest X-Ray with B-Reader

Red Blood Cell Cholinestrerase

Blood Lead 0

Zinc Photoporphyrin

(ZPP)

Diphtheria Tetanus Booster

Hepatitis A Vaccination

Hepatitis B Vaccination

Chromium Examination

HAZWOPER

Medical Evaluation

CDL: DOT

Driver's Cert Exam

Crane Operator Physical Exam

GRAND

TOTALS:

$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

BASE YR- FR OSHA PHYSICALS

FFP

Base Year- Provide Ft Randall Employee OSHA Physicals

MILSTRIP: W59XQG90526450

PURCHASE REQUEST NUMBER: W59XQG90526450

NET AMT

1000AA 1 Job

BASE YR- FR POWERPLANT EMPLOYESS

FFP

Base Year- Provide Ft Randall Powerplant Employees OSHA Physicals

FOB: Destination

MILSTRIP: W59XQG90526450

PURCHASE REQUEST NUMBER: W59XQG90526450

1000AB 1 Job

BASE YR- FR OM & TECH SEC EMPLOYESS

FFP

Base Year- Provide Ft Randall Outside Maintenance & Tech Section Employees

OSHA Physicals

FOB: Destination

OPT 1, YR 2- FR OSHA PHYSICALS

FFP

Option 1, Year 2- Provide Ft Randall Employees OSHA Physicals

2000AA 1 Job

OPTION OPT 1, YR 2- FR POWERPLANT EMPLOYESS

FFP

Option 1, Year 2- Provide Ft Randall Powerplant Employees OSHA Physicals

2000AB

OPT 1, YR 2- FR OM & TECH SEC EMPLOYESS

FFP

Option 1, Year 2- Provide Ft Randall Outside Maintenance & Tech Section

Employees OSHA Physicals

OPT 2, YR 3- FR OSHA PHYSICALS

Option 2, Year 3- Provide Ft Randall Employees OSHA Physicals

3000AA

OPT 2, YR 3- FR OSHA PHYSICALS

FFP

Option 2, Year 3- Provide Ft Randall Employees OSHA Physicals

3000AB

OPT 2, YR 3- FR OM & TECH SEC EMPLOYESS

FFP

Option 2, Year 3- Provide Ft Randall Outside Maintenance & Tech Section

OPT 3, YR 4- FR OSHA PHYSICALS

Option 3, Year 4- Provide Ft Randall Employees OSHA Physicals

4000AA

OPT 3, YR 4- FR OSHA PHYSICALS

FFP

Option 3, Year 4- Provide Ft Randall Employees OSHA Physicals

4000AB

OPT 3, YR 4- FR OM & TECH SEC EMPLOYESS

FFP

Option 3, Year 4- Provide Ft Randall Outside Maintenance & Tech Section

OPT 4, YR 5- FR OSHA PHYSICALS

Option 4, Year 5- Provide Ft Randall Employees OSHA Physicals

5000AA

OPT 4, YR 5- FR OSHA PHYSICALS

FFP

Option 4, Year 5- Provide Ft Randall Employees OSHA Physicals

5000AB

OPT 4, YR 5- FR OM & TECH SEC EMPLOYESS

FFP

Option 4, Year 5- Provide Ft Randall Outside Maintenance & Tech Section

INSPECTION AND ACCEPTANCE TERMS

Supplies/services will be inspected/accepted at:

CLIN INSPECT AT INSPECT BY ACCEPT AT ACCEPT BY

1000 N/A N/A N/A N/A

1000AA Destination Government Destination Government

1000AB Destination Government Destination Government

2000 N/A N/A N/A N/A

2000AA Destination Government Destination Government

2000AB Destination Government Destination Government

3000 N/A N/A N/A N/A

3000AA Destination Government Destination Government

3000AB Destination Government Destination Government

4000 N/A N/A N/A N/A

4000AA Destination Government Destination Government

4000AB Destination Government Destination Government

5000 N/A N/A N/A N/A

5000AA Destination Government Destination Government

5000AB Destination Government Destination Government

DELIVERY INFORMATION

CLIN DELIVERY DATE QUANTITY SHIP TO ADDRESS DODAAC /

CAGE

1000 N/A N/A N/A N/A

1000AA POP 15-JUL-2019 TO

14-JUL-2020

N/A COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

605-487-7845 X 3503

968810

1000AB POP 15-JUL-2019 TO

14-JUL-2020

N/A (SAME AS PREVIOUS LOCATION)

2000 N/A N/A N/A N/A

2000AA POP 15-JUL-2020 TO

14-JUL-2021

N/A COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

605-487-7845 X 3503

2000AB POP 15-JUL-2020 TO

14-JUL-2021

N/A (SAME AS PREVIOUS LOCATION)

3000 N/A N/A N/A N/A

3000AA POP 15-JUL-2021 TO

14-JUL-2022

N/A COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

605-487-7845 X 3503

3000AB POP 15-JUL-2021 TO

14-JUL-2022

N/A (SAME AS PREVIOUS LOCATION)

4000 N/A N/A N/A N/A

4000AA POP 15-JUL-2022 TO

14-JUL-2023

N/A COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

605-487-7845 X 3503

4000AB POP 15-JUL-2022 TO

14-JUL-2023

N/A (SAME AS PREVIOUS LOCATION)

5000 N/A N/A N/A N/A

5000AA POP 15-JUL-2023 TO

14-JUL-2024

N/A COE FT RANDALL PROJECT OFFICE

LISA M DURHAM

USAED, OMAHACENWO-OD-FR

113 RANDALL CREEK ROAD

PICKSTOWN SD 57367

605-487-7845 X 3503

5000AB POP 15-JUL-2023 TO

14-JUL-2024

N/A (SAME AS PREVIOUS LOCATION)

CLAUSES INCORPORATED BY REFERENCE

52.204-4 Printed or Copied Double-Sided on Postconsumer Fiber

Content Paper

MAY 2011

52.204-7 System for Award Management OCT 2018

52.204-13 System for Award Management Maintenance OCT 2018

52.204-16 Commercial and Government Entity Code Reporting JUL 2016

52.204-18 Commercial and Government Entity Code Maintenance JUL 2016

52.212-1 Instructions to Offerors--Commercial Items OCT 2018

52.212-3 Offeror Representations and Certifications--Commercial

Items

OCT 2018

52.212-4 Contract Terms and Conditions--Commercial Items OCT 2018

52.223-17 Affirmative Procurement of EPA-Designated Items in Service and Construction Contracts

AUG 2018

52.225-25 Prohibition on Contracting with Entities…