PWS_FY13.pdf

PERFORMANCE WORK STATEMENT

OCCUPATIONAL HEALTH

PROCUREMENT OF MEDICAL SURVEILLANCE EXAMINATIONS

Task Order Objective: This contract is to provide onsite Medical Surveillance Physical Exams in support of the Idaho Army National Guard.

Deliverable Performance Standard

Acceptable Quality Level (AQL) Method Used / Frequency

Contractor coordinates with

OHN/OHT and provides adequate exam location and all appropriate equipment to accomplish medical services.

Go/No Go Adequate examination location is provided for the event. Equipment is sterile and in good operating condition and adequate supplies are on hand.

Review

Spot Check or inspection

Customer

Complaint

Contractor coordinates with OHN and provides qualified and sufficient personnel during services.

Go/No Go Vendor provides sufficient numbers of qualified required personnel to conduct medical services.

Contractor personnel to posses appropriate level of credentialing

Contractor provides Event

Coordinator to oversee execution of service events.

Go/No Go Event Coordinator is responsible for smooth execution of services

Contractor performs services according to set schedule of location and number of physicals determined.

Go/No Go Contractor completes testing as discussed verbally during the planning phase of “number of physicals and the event location”

Contractor completes all required testing as outlined by section 4.0

Specific Tasks of the PWS.

Completes

100% of all identified testing

Contractor completes all identified medical tests

– Blood pressure, physician exam, IAW references supplied in PWS as well as current published standards.

Contractor completes any required paperwork for medical files – forms, temporary or permanent profiles.

Completes

98% of needed paperwork

Updates to personnel medical files must be error free and confidentiality maintained.

Results to follow up in OHN office must be at

100%

Contractor coordinates any special medical service requirements – critical findings within specified time period as per PWS Para. 4.8.

98% of reportable findings

Event coordinator reports any special event or post event services until completed and updates OHN.

Contractor completes all written data and reporting no later than 5 business days from completion of employee testing, verbal data available within 72 hrs. Per PWS

Para. 8.1 & 8.2.

5 business days Contractor reports all results within 5 business days

95% of time, verbal results available to OHN within

72 hrs. 95% of time.

1.0 GENERAL

1.1. This Performance Work Statement (PWS) will outline the procedure for procurement of medical surveillance examinations required for 100% of the Idaho Army National Guard

(IDARNG) full time civilian federal technician workforce in select maintenance areas. The location for services will be within Boise Idaho city limits and all services will be performed at a single location. The estimated number of personnel to be examined is 250. Contractors will provide all of the examinations as defined below in Section 4.0, and the contractor will furnish all items necessary to meet the requirements of this PWS. The examinations shall include personnel assigned to positions requiring specific standards of physical fitness. This PWS does not cover State of Idaho employees, civilian contractors, and IDARNG Active Guard/Reserve

(AGR) or part time soldiers. The Government has the right to increase and/or decrease the number of employees for service.

1.2. Background: The Idaho Army National Guard is a military organization with both state and national missions. There is a command focus to maintain a medically and dentally healthy force that is able to meet the rigors of any mission assigned. Pre-employment and annual physicals are required to meet Army and Federal standards for all federal technicians who are exposed to situations that could be hazardous to their health.

1.3. Objectives: To provide pre-employment and annual physical exams in accordance with the contract, performance work statement, quality assurance surveillance plan, and service delivery summary.

1.4. Period of Performance: The period of performance shall be for one (1) Base Year of 12 months.

1.5 General Information

1.5.1. Quality Control: The contractor shall develop and maintain an effective quality control program (QCP) to ensure services are preformed in accordance with this PWS. The contractor shall develop and implement procedures to identify, prevent, and ensure non-recurrence of defective services. The contractor’s quality control program is the means by which he assures himself that his work complies with the requirement of the contract. The QCP is to be delivered within 30 days after contract award. Three copies of a comprehensive written QCP shall be submitted to the contracting officer (KO) and Contracting Officer Representative (COR). After acceptance of the quality control plan the contractor shall receive the contracting officer’s acceptance in writing of any proposed change to his QC system.

1.5.2. Quality Assurance: the Government shall evaluate the contractor’s performance under this contract in accordance with the Quality Assurance Surveillance Plan (QASP). This plan is primarily focused on what the Government must do to ensure that the contractor has performed in accordance with the performance standards. It defines how the performance standards will be applied, the frequency of surveillance, and the minimum acceptable defect rate(s).

1.5.3. Recognized Holidays: the contractor is not required to perform services on the below holidays:

New Year’s Day Labor Day Martin

Luther King Jr.’s Birthday Columbus Day

President’s Day Veterans Day

Memorial Day Thanksgiving Day

Independence Day Christmas Day

1.5.4. Hours of Operation: The contractor is responsible for conducting business during normal business hours Monday through Friday except Federal holidays or when the Government facility is closed due to local or national emergencies, administrative closings, or similar Government directed facility closings. The Contractor must at all times maintain an adequate workforce for the uninterrupted performance of all tasks defined within this PWS. When hiring personnel, the

Contractor shall keep in mind that the stability and continuity of workforce are essential.

1.5.5. Place of Performance: The work to be performed under this contract will be performed at the contractor’s Boise facility.

1.5.6. Type of Contract: The Government will award a Firm Fixed Price service contract with a

Not To Exceed cost constraint for the period of one (1) year.

1.5.7. Security Requirements: There are no security clearance requirements for this contract, however all deliverables will be handled For Official Use Only.

1.5.7.1. Physical Security: The contractor shall be responsible for safeguarding all government equipment, information, and deliverables related to the scope of this contract.

1.5.8. Post Award Conference/Period Progress Meetings: The contractor agrees to attend any post award conference convened by the contracting activity or contract administration office in accordance with Federal Acquisition Regulation Subpart 42.5. The contracting officer, COR, and other Government personnel, as appropriate, may meet periodically with the contractor to review the contractor’s performance. At these meetings the contracting officer will apprise the contractor of how the government views the contractor’s performance and the contractor ill apprise the Government of problems, if any, being experienced. Appropriate action shall be taken to resolve outstanding issues. These meetings shall be at no additional cost to the

Government.

1.5.9. Contracting Officer Representative (COR): the COR will be identified by separate letter.

The COR monitors all technical aspects of the contract and assists in contract administration.

The COR is authorized to perform the following functions: assure the the Contractor performs the technical requirements of the contract, perform inspections necessary in connection with contract performance, maintain written and oral communications with the contractor concerning technical aspects of the contract, issue written interpretations of technical requirements, monitor contractors performance and notifies both the Contracting Officer and contractor of any deficiencies, coordinates availability of government furnished property, and provides site entry to contractors personnel. A letter of designation issued to the COR, a copy of which is sent to the contractor, states the responsibilities and limitations of the COR, especially with regard to changes in cost or price, estimates or changes in delivery dates. The COR is not authorized to change any of the terms and conditions of the resulting order.

1.5.10. Key Personnel: the contractor shall provide a contract manager who shall be responsible for the performance of the work. The name of this person and an alternate who shall act for the contractor when the manager is absent shall be designated in writing to the contracting officer.

The contract manager or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The contract manager or alternate shall be available during normal business hours, Monday thru Friday except Federal holidays or when the

Government facility is closed for administrative reasons. The following personnel are considered key personnel by the government:

Contracting Officer: MAJ Sandra Snediker

Administrator: SGT Christopher Cox

Contracting Officer Representative: CPT Tina Williams

1.5.11. Data Rights: The Government has unlimited rights to all documents/material produced under this contract. These documents and materials may not be used or sold by the contractor without written permission from the Contracting Officer. All materials supplied to the

Government shall be the sole property of the Government and may not be used for any other purpose. This right does not abrogate any other Government rights.

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

Subpart 9.5. The contractor shall notify the Contracting Officer immediately whenever it becomes aware that such access or participation may result in any actual or potential OCI and shall promptly submit a plan to the Contracting officer to avoid or mitigate an such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the

Contracting Officer and in the event the Contracting officer unilaterally determines that any such

OCI cannot be satisfactorily avoided or mitigated, the Contracting Officer may affect other remedies as he or she deems necessary, including prohibiting the contractor from participation in subsequent contract requirements which may be affected by the OCI.

1.6. The sole IDARNG officers authorized to make appointments and discuss information for these services as defined by this PWS are the State Occupational Health Nurse (SOHN) and the

State Safety Manager (SSM). The contract will be finalized by the IDARNG contracting officer

(KO) and only the KO can make changes to the contracting action. Reference DoD 6025.18-R

(DoD Health Information Privacy Regulation) and DoD 8580.02-R (DoD Health Information

Security Regulation). Contractor does not release medical information to personnel not specifically mentioned in this PWS.

1.7. As a Quality Control/Assurance measure, all test results will be forwarded directly to the

State Occupational Health Nurse (SOHN) by the vendor and will be checked for completeness and accuracy against the master roster of employees. Time periods allotted for written report delivery and availability of verbal reporting is identified in section 8.0. Address and phone number for the SOHN is:

Idaho Army National Guard

ATTN: CPT Tina Williams, SOHN

4228 W. Guard St, BLDG 665

Boise, ID 83705-8095.

(208) 272-3735

1.8. The Government will evaluate the quality of professional and administrative services provided as detailed in the Medical Quality Assurance Plan of this PWS, but retain no control over the medical professional aspects of services rendered such as testing procedures, etc. The

Contractor will provide Board Certified Occupational Health Physician(s), supervision, all labor, tools, materials, equipment, and incidentals required to conduct the Medical Surveillance

Examinations for the IDARNG.

2.0 DEFINITIONS and ACRONYMS

2.1. Definitions

2.1.1. Contractor: A supplier or vendor awarded a contract to provide specific supplies or services to the Government. The term used in this contract refers to the prime.

2.1.2. Contracting Officer: A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the Government. Not: The only individual who can legally bind the Government.

2.1.3. Contracting Officers Representative (COR): An employee of the U.S. Government appointed by the contracting officer to administer the contract. Such appointment shall be in writing and shall state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as the direction is within the scope of the contract, does not constitute a change, and has no funding implications. This individual does

NOT have authority to change the terms and conditions of the contract.

2.1.4. Defective Service: A service output that does not meet the standard of performance associated with the Performance Work Statement.

2.1.5. Deliverable: Anything that can be physically delivered, but may include no manufactured things such as meeting minutes or reports.

2.1.6. Key Personnel: Contractor personnel that are evaluated in a source selection process and that may be required to be use in the performance of a contract by the Key Personnel listed in the

PWS. When key personnel are used as an evaluation factor in best value procurement, an offer can be rejected if it does not have a firm commitment from the persons that are listed in the proposal.

2.1.7. Physical Security: Actions that prevent the loss or damage of Government property.

2.1.8. Quality Assurance: The Government procedures to verify that services being performed by the contractor are performed according to acceptable standards.

2.1.9. Quality Assurance Surveillance Plan (QASP): An organized written document specifying the surveillance methodology to be used for surveillance of contactor performance.

2.1.10. Quality Control: All necessary measure taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

2.1.11. Subcontractor: One that enters into a contract with a prime contractor. The Government does not have privity of contract with the subcontractor.

2.1.12. Work Day: the number of hours per day the contractor provides services in accordance with the contract.

2.1.13. Work Week: Monday through Friday, unless specified otherwise.

2.2. ACRONYMS

ACOR Alternate Contracting Officer’s Representative

AFARS Army Federal Acquisition Regulation Supplement

AR Army Regulation

AGR Active Guard/Reserve CCE Contracting Center of Excellence

CFR Code of Federal Regulations

CONUS Continental United States (excludes Alaska and Hawaii)

COR Contracting Officer Representative

COTR Contracting Officer’s Technical Representative

COTS Commercial-Off-the-Shelf

DA Department of Army

DD250 Department of Defense Form 250 (receiving report)

DD254 Department of Defense Contract Security Requirements List

DFARS Defense Federal Acquisition Regulation Supplement

DMDC Defense Manpower Data Center

DoD Department of Defense

FAR Federal Acquisition Regulation

HIPAA Health Insurance Portability and Accountability Act of 1996

IDARNG Idaho Army National Guard

KO Contracting Officer

OCI Organizational Conflict of Interest

OCONUS Outside Continental United Sates (including Alaska and Hawaii)

ODC Other Direct Costs

OHN Occupational Health Nurse

OHT Occupational Health Technician

PIPO Phase In/Phase Out

POC Point of Contract

PRS Performance Requirements Summary

PWS Performance Work Statement

QA Quality Assurance

QAP Quality Assurance Program

QASP Quality Assurance Surveillance Plan

QC Quality Control

QCP Quality Control Program

TE Technical Exhibit

3.0 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 will evaluate the quality of professional and administrative services provided, while the Government retains no control over the medical and professional aspects of services rendered. The Contractor will indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance. The Contractor will maintain medical liability insurance, in a coverage amount acceptable to the Contracting Officer, which is not less than the amount normally prevailing within the local community for the medical specialty concerned. The

Contractor is required to ensure that its subcontractors, if any, for provisions of health care services, contain the requirements of the clause at 52.237-7, Indemnification and Medical

Liability Insurance, including the maintenance of medical liability insurance.

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, 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 consultation services.

3.5. Contractor shall arrange for the opportunity to consult with the OHN or OHT of the

IDARNG 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 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 provide documented proof of current required technician certification/license and equipment calibration with their proposal.

4.0 SPECIFIC TASKS

4.1. Contractor will provide vital signs to include height, weight, blood pressure, pulse and respirations.

4.2. Physical exams will be performed by an Occupational Health Board Certified physician.

Contractors will provide a back examination which will include a Kraus-Weber Back Strength and Flexibility Rating. Note any pain or recommended lifting limitations if less than 50 lbs.

4.3. 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, at no additional cost, 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 all of the following;

a. Complete Blood Count (CBC) including differential and platelet counts (actual).

b. Urinalysis (UA) screening (dipstick UA).

c. Chemistry Panel (serum) including a minimal of Glucose, BUN, Creatinine, electrolytes, liver function tests (to include GGTP), and lipid panel (to include Triglycerides, LDL, HDL, and ratio). Note: this will be non-fasting (random).

4.4. 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.

a. 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 8 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, including respirator use clearance, and given to employee at time of visit. Questionable/failing testing will be reported to the OHN during the initial visit.

4.5. Contractor shall ensure dermatological examinations must be performed by a physician and include an inspection of the entire integumentary system with emphasis on areas most likely to be affected by the employee's occupational (i.e. radiation) exposures. Documentation will include the presence of any dermatomes or lesions of the skin. If a dermatological referral is recommended, it can only be to certified dermatologist or Occupational Health Physicians. Prior coordination with the SOHN or OHT is required before referrals are made.

4.6. Contractor will ensure that vision screenings are in accordance with DA PAM 40-506 using multiphasic vision screening equipment (Titmus type) to measure the following primary visual skills:

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.

4.7. 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:

a. Chest X-rays are only performed for asbestos exposed employees.

b. Be a posterior-anterior (PA) and left lateral view.

4.8. Contractor shall ensure instrumentation meets and/or exceeds appropriate performance standards, and accuracy must be verified in accordance with current Occupational Medicine

Certification standards. Any abnormal clinical findings which indicate the possibility of a present danger to the employee will be confirmed by repeat analysis at no additional charge.

Confirmed abnormal results will be reported within 24 hrs of findings to the OHN.

4.9. Contractor will provide written reports/results to the State Occupational Health Office, address below. Under no circumstances will written results be given to the employee’s supervisor in accordance with The Privacy Act of 1974.

4228 W. Guard St, BLDG 665

5.0 APPLICABLE TECHNICAL ORDERS, SPECIFICATIONS, REGULATIONS,

MANUALS

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

Standards.

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

Employees.

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

5.4. Threshold Limit Values and Biological Exposure Indices (TLVs), American Conference of

Governmental Industrial Hygienists (ACGIH), Cincinnati, Ohio.

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

5.6. Department of Defense 6055.05M, Occupational Medical Surveillance Manual;

incorporating Change 1, 16 Sept 2008.

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

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

5.9. Headquarters, Department of the Army Pamphlet (DA PAM) 40-501 Hearing Conservation

10 Dec 1998.

5.10. Headquarters, Department of the Army Pamphlet (DA PAM) 40-506 Vision Conservation

15 Jul 2009.

5.11. Conference of Governmental Industrial Hygienists (ACGIH), Cincinnati, Ohio.

6.0 PERSONAL PROTECTIVE EQUIPMENT (PPE)

6.1. 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.

6.2. Contractor shall ensure each healthcare worker complies with the requirements of 29 CFR

1910.1030 Blood borne Pathogens Standard.

7.0 INFECTIOUS WASTE DISPOSAL

7.1. 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.

7.2. 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.

8.0 MEDICAL REPORTS AND RECORDKEEPING

8.1 Contractors shall contact the SOHN by telephone at 208.272.3735 within 24 hrs. of findings if results of medical surveillance screening(s), which are questionable and /or of critical significance and /or require follow-up. Contractor shall send all results to include all diagnostic tests, graphs, charts, reports, questionnaires, waivers, employee consent forms, physical findings, and examination results to the State Occupational Health Nurse within 5 working days of completion of testing 95% of the time to:

4228 W. Guard St, BLDG 665

8.2. Contractor will have information available to provide a verbal report to SOHN within 72 hours of testing completion if contacted by telephone by SOHN. The verbal information should be readily available 95% of the time.

8.3. Contractor is to inform each employee to sign a release to send results of clinical testing to the member at their home of record (HOR). A confidential envelope will be utilized when mailing personal exam results to employee’s HOR.

8.4. 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).

854. Contractor shall ensure that each employee signs the Privacy Act Statement (DD Form

2005) during the registration process.

9.0 EXAMINATION SCHEDULING

9.1. Coordination of scheduling shall be a joint effort between the SOHN, and the Contractor, a draft copy of the schedule will be initiated by the SOHN and sent to the Contractor for review and any needed adjustments. Scheduling will not exceed one patient/employee per 15 minute intervals. All workdays include a one-hour lunch break. No testing shall be performed between

1130 – 1230 hours.

9.2. 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, SOHN, and the Facility(ies). 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.

10.0 SERVICE DELIVERY SUMMARY (SDS)

10.1. 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 100% of the time for all physicians &

Technicians (Para 3.2, 3.3, 3.4, 3.7)

Equipment Certification Instrumentation meets or exceed

Performance standards, 100% of the

Time (Para 3.7)

Medical Surveillance All Federal Civilian Technicians have

Rating Description

Green Yes performance and technical specifications are being met at AQL.

Yellow

Yes, performance and technical specifications are currently being met at the minimum AQL, but the following service / deliverable needs contractor attention.

The Customer must identify what component of the deliverable and/or service requires attention.

Red

No, performance and technical specifications are not being met at AQL and the following service / deliverable needs immediate contractor resolution.

Performance activity will stop until the COR/OHPM has determined complete resolution.

The Customer must identify what component of the deliverable and/or service is below the minimum AQL.

Been examined, 100% of the time (see

Para 1.1)

Infectious Waste Disposal All sharp instruments, blood, and urine is

Handled and disposed of in accordance with

Federal, state, and local regulations, 100%

Medical Reports and Recordkeeping Privacy Act statement and reports for each

Federal Civilian Technician are Submitted within time constraints 95% of the time (see all

Para 8.1). Verbal information available

95% of time within specified time constraints (Para 8.2).

MEDICAL QUALITY ASSURANCE PLAN WORKSHEET

Performance Rating

Deliverable/Service

Quality

Rating

Causative Factors Effect on Mission Action Required / Date

Contractor coordinates with

OHN/OHT and provides adequate exam location and all appropriate equipment to accomplish medical services.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor coordinates with

OHN and provides qualified and sufficient personnel during services.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor provides Event Coordinator to oversee execution of service events.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor performs services according to set schedule of location and number of physicals

Green Comments Unnecessary for “Green” QA Rating.

Yellow determined. Red

Contractor completes all required testing as outlined by section 4.0

Specific Tasks of the PWS.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes any required paperwork for medical files – forms, temporary or permanent profiles.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor coordinates any special medical service requirements – critical findings within specified time period as per PWS Para. 4.8.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes all written data and reporting no later than 5 business days from completion of employee testing, verbal data available within 72 hrs. Per PWS

Para. 8.1 & 8.2.

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red