PWS_-_Attachment_1.pdf

PERFORMANCE WORK STATEMENT (PWS) FOR

Medical Surveillance Services EOD-Firefighters Physicals

1.1 General:

1.2 Scope: The contractor shall provide all personnel, equipment, tools, materials, supervision, and quality control necessary, except as specified in Paragraph 3.0 as Government Furnished, to perform Medical Surveillance Services, as defined in this PWS.

1.3 Background:

The Michigan Army National Guard (MIARNG) requires support for EOD and Firefighter Occupational Medical Surveillance Examination Program in accordance with the Occupation Safety and Health Association (OSHA) and other regulations. Due to the majority of personnel being spread out across the entire state of Michigan with some areas having distances of greater than 150 miles to an established facility, services should be provided in a mobile setting.

The purpose of the Occupational Medical Surveillance Examination Program is to provide job-related Medical Surveillance Examinations and Occupational Health Services to members of the MIARNG who are or could potentially be exposed to health hazards in the work environment in the commission of their duties as EOD Specialists and Firefighters. The examination shall include personnel assigned to positions requiring specific standards of physical fitness.

Personnel not included under these examinations are State Employees, civilian contractors, and dual-status Title 32 Technicians.

The Government may 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 Occupational Health Physician(s), supervision, all labor, tools, materials, equipment, and incidentals required to conduct the Medical Surveillance Examination / Occupational Health Services for the MIARNG.

1.4 Period of Performance (PoP): The period of performance is 12 months.

1.5 General Information:

1.5.1 Reserved.

1.5.2 Quality Assurance (QA): The Government will 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 acceptable quality level(s) (defect rate(s)).

1.5.3 Recognized Holidays: The following are recognized US holidays. The contractor shall not perform services on these days:

Attachment 1 5 September 2018

1.5.3.1 New Year’s Day: January 1st

1.5.3.2 Martin Luther King, Jr.’s Birthday

1.5.3.3 President’s Day

1.5.3.4 Memorial Day

1.5.3.5 Independence Day: July 4th

1.5.3.6 Labor Day

1.5.3.7 Columbus Day

1.5.3.8 Veteran’s Day: November 11th

1.5.3.9 Thanksgiving Day

1.5.3.10 Christmas Day

1.4.4 Place and Performance of Services:

Coordination of scheduling shall be a joint effort between the Occupational Health Manager and the Contractor, a draft copy of the schedule will be initiated by the Occupational Health Manager and sent to the Contractor for review and any needed adjustments. One patient/employee per 15 minute intervals. Testing shall be performed in a mobile environment.

Place of performance will be at the Contractor’s site.

1.4.5 Reserved.

1.4.6 Reserved

1.4.7 Reserved:

1.4.8 Post Award Conference/Periodic Progress Meetings: The contractor agrees to attend any post award conference convened by the KO in accordance with Federal Acquisition Regulations Subpart 42.5. The KO, Contracting Officer’s Representative (COR), and other Government personnel, as appropriate, may meet periodically with the contractor to review the contactor’s performance. At these meetings, the Contacting Officer will apprise the contractor of how the Government views the contractor’s performance and the contractor shall apprise the Government of problems, if any, being experienced The contractor shall resolve outstanding issues raised by the Government. Contractor attendance at these meetings shall be at no additional cost to the Government.

1.4.9 Contract Manager (CM): The contactor shall designate a CM who shall ensure performance under this contract. The name of this person, and an alternate who shall act for the contractor when the CM is absent, shall be designated in writing to the KO. The CM or alternate shall have full authority to act for the contractor on all contract matters relating to daily operation of this contract. The CM shall work through the COR, (or the KO if a COR is not assigned), to resolve issues, receive technical instructions, and ensure adequate performance of services. The CM shall ensure that contractor employees do not perform any services outside the scope of the contract without an official modification issued by the KO. The CM shall ensure contractor employees understand that services performed outside the scope of the contract are performed wholly at the expense of the contractor.

1.4.10 Identification of Contractor Employees: All contractor personnel attending meetings, answering Government telephones and working in other situations where their contractor status is not obvious to third parties are required to identify themselves as such to avoid creating an impression that they are Government employees. The contractor shall ensure that all documents or reports produced by contractor personnel are suitably marked as contractor products or that contractor participation is appropriately disclosed. The contractor’s status as a “contractor” shall be predominantly displayed in all correspondence types (to include signature blocks on e-mail) and dealings with Government or non-Government entities/ Contractor personnel shall wear identification badges distinguishing themselves as such. The badges shall have the company name, employee name and the word “contractor” displayed. The contractor shall retrieve all identification media (including vehicle passes) from their employees who depart employment for any reason. All identification media (i.e., badges and vehicles passes) shall be returned to the KO within 14 days of an employee’s departure.

1.4.11. Combating Trafficking in Persons: The United States Government has adopted a zero tolerance policy regarding trafficking in persons. Contractors and contractor employees shall not engage in severe forms of trafficking in persons during the period of performance of the contract; procure commercial sex acts during the period of performance of the contract; or use forced labor in the performance of the contract. The Contractor shall notify its employees of the United States Government’s zero tolerance policy, the actions that will be taken against employees for violations of this policy. Such actions may include, but are not limited to, removal from the contract, reduction in benefits, or termination of employment. The contractor shall take appropriate action, up to and including termination, against employees or subcontractors that violate the US Government policy as described at FAR 22.17.

1.4.12 Contractor Travel: Contractor travel is not authorized.

1.4.13 Reserved

1.4.14 Organizational Conflicts of Interest (OCI): The contractor and subcontractor personnel performing services 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 analyses, specifications or work statements, etc.) or perform evaluation services which may create a current or subsequent OCIs, as defined in FAR Subpart 9.5. The contractor shall notify the KO 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 KO to avoid or mitigate any such OCI. The contractor’s mitigation plan will be determined to be acceptable solely at the discretion of the KO and in the event the KO unilaterally determines that any such OCI cannot be satisfactorily avoided or mitigated, the KO may affect other remedies as he or she deems necessary, including prohibiting the contractor from participation in subsequent contracted requirements which may be affected by the OCI.

2.1 Definitions and Acronyms:

2.2 DEFINITIONS

2.2.1 CONTRACTOR. A supplier or vendor awarded a contract to provide specific supplies or service to the government. The term used in this contract refers to the prime.

2.2.2 CONTRACTING OFFICER (KO). A person with authority to enter into, administer, and or terminate contracts, and make related determinations and findings on behalf of the government. Note: The only individual who can legally bind the government.

2.2.3 CONTRACTING OFFICER'S REPRESENTATIVE (COR). An employee of the U.S.

Government designated by the KO to monitor contractor performance. Such appointment will be in writing and will state the scope of authority and limitations. This individual has authority to provide technical direction to the Contractor as long as that 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.

2.2.4 DEFECTIVE SERVICE. A service output that does not meet the standard of performance associated with the Performance Work Statement.

2.2.5 DELIVERABLE. Anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.2.6 KEY PERSONNEL. Contractor personnel that are evaluated in a source selection process and that may be required to be used 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.

2.2.7 PHYSICAL SECURITY. Actions that prevent the loss or damage of Government property.

2.2.7.1 When medical surveillance services are to be provided at a Michigan National Guard installation or separate facility, the contractor’s employees shall become familiar with and obey the regulations of the installation or facility. Vehicles operated by contractor personnel are subject to search pursuant to applicable regulations. Contractor employees should only enter restricted areas when required to do so and only upon prior approval. All contractor employees shall carry proper identification with them at all times. Unscheduled gate closures at installations may occur at any time causing all personnel entering or exiting a closed installation to experience a delay. This cannot be predicted or prevented. Contractors are not compensated for unexpected closures or delays.

2.2.8 QUALITY ASSURANCE. The government procedures to verify that services being performed by the Contractor are performed according to acceptable standards.

2.2.9 QUALITY ASSURANCE SURVEILLANCE PLAN (QASP). An organized written document specifying the surveillance methodology to be used for surveillance of contractor performance.

2.2.10 QUALITY CONTROL. All necessary measures taken by the Contractor to assure that the quality of an end product or service shall meet contract requirements.

2.2.11 SUBCONTRACTOR. One that enters into a contract with a prime contractor. The Government does not have privity of contract with the subcontractor.

2.2.12 WORK DAY. The number of hours per day the Contractor provides services in accordance with the contract.

2.2.13 WORK WEEK. Monday through Friday, unless specified otherwise.

2.2 ACRONYMS:

AFARS Army Federal Acquisition Regulation Supplement AR Army Regulation AT/OPSEC Antiterrorism/Operational Security CFR Code of Federal Regulations CONUS Continental United States (excludes Alaska and Hawaii) COR Contracting Officer Representative COTS Commercial-Off-the-Shelf DA Department of the Army DD250 Department of Defense Form 250 (Receiving Report) DD254 Department of Defense Contract Security Requirement List DFARS Defense Federal Acquisition Regulation Supplement DOD Department of Defense FAR Federal Acquisition Regulation GFP/M/E/S Government Furnished Property/Material/Equipment/Services IA Information Assurance IS Information System(s) KO Contracting Officer OCI Organizational Conflict of Interest ODC Other Direct Costs PII Personally Identifiable Information PIPO Phase In/Phase Out

POC Point of Contact 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 Government Furnished Property, Material, Equipment and Services (GFP/M/E/S): The Government will not provide property, material, equipment, and/or services.

4.1 Contractor Furnished Property, Materials, and Equipment (CFP/M/E):

4.2 General: The contractor shall furnish everything required to perform these services as indicated in Paragraph 1.1.

5.1 Requirements:

5.2 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. The Contractor will indemnify the Government for any liability producing act or omission by the Contractor, its employees and agents occurring during contract performance.

5.2.1 Contractor shall 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.

5.2.2 Contractor shall 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.

5.2 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.

5.3. 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.

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

5.5. Contractor shall arrange for the opportunity to consult with an Occupational Health Manager of the MIARNG by telephone to coordinate or resolve issues that might arise before, during, and after the testing period.

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

5.7. Contractor shall provide vital signs to include height, weight, blood pressure, pulse and respirations.

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

5.9. 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. The estimated number of personnel to receive audiograms are no more than 400.

5.9.1 Hearing screenings shall be conducted only on employees exposed to occupational noise > 85 dBA or 140 dBA impact noise.

5.9.2 All hearing tests shall be entered into DOEHRS-HC.

5.9.3 Otoscopic Exam.

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

5.9.5 Hearing aids must be removed.

5.9.6 Employee must be noise free for at least 14 hours prior to screening.

5.9.7 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 and if there is still a STS notify the Occupational Health Manager within 10 days so that timely retesting can be scheduled.

5.10 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 are no more than 200.

5.10.1 Screenings shall only be conducted on employees exposed to respiratory hazards that will require a respirator to mitigate their hazards that are above the action level.

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

5.10.2.1 Follow NIOSH and ATS-ERS standard requirements:

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

5.10.2.3 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.

5.10.2.4 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.

5.10.2.5 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.

5.10.2.6 Use measured height not reported height by the nearest half inch without footwear.

5.10.2.7 Indicate source of reference value on reports for adjusted predicted value.

5.10.2.8 Ensure test is given when patient has abstained from smoking for 1 hour prior.

5.10.2.9 Ensure the patient has not had cold, flu or allergies within two weeks of the test.

5.10.2.10 Ensure the patient has not used an inhaler prior to test that could still be in the patient’s system.

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

5.10.4 Respirator clearance shall be documented and a copy given to employee at time of visit.

5.11 Contractor shall provide quantitative fit testing in accordance with 29 CFR 1910. 134 appendix A. The estimated number of personnel to receive fit testing is no more than 200.

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

5.12 Contractor shall ensure that vision screenings are in accordance with DA PAM 40-506 using multiphasic vision screening equipment to measure the following primary visual skills.

5.12.1 Visual acuity for distance and near.

5.12.2 Lateral phorias for distance and near.

5.12.3 Vertical phorias for distance and near.

5.12.4 Depth perception.

5.12.5 Color perception.

5.12.6 Peripheral vision.

5.13 Contractor shall ensure laboratory tests are 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:

5.13.1 Blood Chemistries (serum) with H&H, BUN and Creatinine. Estimated quantity: 400.

5.13.2 Liver Function to include AP and if abnormal include GGTP. Estimated quantity: 400.

5.14 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.

5.15 Contractors 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 no more than 200.

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

5.15.2 Be a posterior-anterior and left lateral view.

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

5.17 Reserved.

5.18 Reserved.

5.19 PERSONAL PROTECTIVE EQUIPMENT (PPE)

5.19.1 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.

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

5.20 INFECTIOUS WASTE DISPOSAL

5.20.1 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.

5.20.2 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.

5.21 MEDICAL REPORTS AND RECORDKEEPING

5.21.1 Contractors shall immediately notify the Occupational Health Manager by telephone 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 Occupational Health Manager within 30 working days of completion of testing to:

Michigan Army National Guard ATTN: MAJ Karen Sims 3411 N. Martin Luther King Jr Blvd Lansing, MI 48906

5.21.2 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).

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

5.22 EXAMINATION SCHEDULING

5.22.1 Coordination of scheduling shall be a joint effort between the Occupational Health Manager and the Contractor, a draft copy of the schedule will be initiated by the Occupational Health Manager and sent to the Contractor for review and any needed adjustments. One patient/employee per 15 minute intervals.

5.22.2 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 Manager 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.

5.23 Contractor Manpower Reporting Application (CMRA):

5.23.1 The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the Michigan Army National Guard via a secure data collection site.

5.23.2 The contractor shall completely fill in all required data fields using the following web address: http://www.ecmra.mil/. Reporting inputs shall be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year, beginning with 2013. Contractors may direct questions to the help desk at http://www.ecmra.mil.

http://www.ecmra.mil/ http://www.ecmra.mil/

6.0 Applicable Publications: Publications applicable to this PWS are listed below:

Publication (Chapter/Page)

Date of Publication

Mandatory or Advisory

Website

Occupational Safety and Health Standards.

Title 29, Code of Federal Regulations, Part 1910

15 Jul 1993 Mandatory https://www.osha.gov/pls/osh aweb/owadisp.show_docume nt?p_table=STANDARDS&p

_id=9696

Safety and Health Provisions for Federal Employees

Title 29, Code of Federal

Regulations, Part 1960

26 Nov 2004 Mandatory https://www.osha.gov/pls/osh aweb/owadisp.show_docume nt?p_table=STANDARDS&p

_id=11262

Threshold Limit Values and Biological Exposure

Indices (TLVs), American Conference of

Governmental Industrial Hygienists (ACGIH), Cincinnati, Ohio.

31 Dec 2005 Advisory http://www.acgih.org/forms/st ore/ProductFormPublic/docu mentation-of-the-threshold-limit-values-and-biological-exposure-indices-7th-edition- 2006-supplement

Army Regulation 40-5, Preventive Medicine

25 May 2007 Mandatory www.apd.army.mil/epubs/DR _pubs/DR_a/pdf/web/p40_11.

pdf

Department of Defense 6055.05M, Occupational Medical Surveillance Manual

2 May 2007 Mandatory www.dtic.mil/whs/directives/ corres/pdf/605505mp.pdf

Army Regulation 11-34, The Army Respiratory

Protection Program

15 Feb 1990 Mandatory www.dtic.mil/dtic/tr/fulltext/u 2/a401944.pdf

Headquarters, Department of the Army Pamphlet (DA

PAM) 40-501

Hearing Conservation

10 Dec 1998 Mandatory https://phc.amedd.army.mil/to pics/workplacehealth/vcr/Pag es/PolicyandDoctrine.aspx

Headquarters, Department of the Army Pamphlet

15 Jul 2009 Mandatory https://phc.amedd.army.mil/to pics/workplacehealth/vcr/Pag http://www.osha.gov/pls/osh http://www.osha.gov/pls/osh http://www.acgih.org/forms/st http://www.apd.army.mil/epubs/DR http://www.dtic.mil/whs/directives/ http://www.dtic.mil/dtic/tr/fulltext/u

TECHNICAL EXHIBIT 1

Deliverables Schedule

PWS Reference / Deliverable Title

Frequency Number of Copies

Medium/Format Submit To

5.1 Insurance &

Licensed and/or certified staff for all physicians and technicians

As needed 1 Electronic Submission

COR

5.16 Equipment

Certification

As needed Original(s) Electronic Submission

COR

5.7-5.15 Medical Surveillance

As needed As needed Electronic Submission

COR

5.20 Infectious

Waste Disposal

As needed N/A Electronic Submission

COR

5.21 Medical

Reports and

Recordkeeping

As needed As needed Electronic Submission

COR

TECHNICAL EXHIBIT 2

Estimated Workload Data

The estimated number of personnel to be examined is 840.

The Government has the right to increase and/or decrease the number of employees/military personnel and the locations for service.

TECHNICAL EXHIBIT 3

Performance Requirements Summary

PWS

Paragraph

Task Performance Standard

Acceptable Quality Levels

(AQL)

Surveillance Method / By

Whom

5.1 Provide qualified

personnel Insurance and

Licenses for staff are maintained

100% of the time

0% allowed to be uninsured or not licensed

Periodic Inspection/COR

5.16 Equipment

Certification

Equipment shall be certified 100% of the time;

Provide certificates timely 95% of the time

0% allowed use of uncertified equipment; 5% certifications provided late

Periodic Inspection/COR

5.7-5.15 Medical Surveillance

95% timely surveillance

5% surveillance provided untimely

Periodic Inspection/COR

5.20 Infectious Waste

Disposal

100% compliant with handling of infectious waste

0% non-compliance

Random Inspection/Periodic Inspection/COR

5.21 Medical Reports

and

Recordkeeping

Reports submitted timely 95% of the time

5% reports submitted late

Periodic Inspection/COR

PRICE LIST

Description Amount

Physical Exam Components:

Physical Exam- performed per Michigan Army National Guard specifications $135.00

OSHA Respirator Questionnaire Review and Determination 15.00

Audiogram by Certified Hearing Conservationist Physician 35.00

Vision: Titmus Test and Amisier Grid 30.00

Fecal Occult Blood (for patients over 40 yrs) 35.00

Chest Xray (PA/LAT VIEWS) 65.00

Pulmonary Function Testing (Spirometry) performed by licensed physician -3 Trials 50.00

Quantitative Fit Testing - Army National Guard to supply mask 30.00

Laboratory Testing (If not done with physical exam, a $25.00 Office Visit will apply):

Urine Specific Gravity (Microscopic Urine) 15.00 Heavy Metals (Blood) - Cadmium, Arsenic, Mercury, Lead 94.00

Heavy Metals (Urine) - Cadmium, Arsenic, Mercury, Lead 78.00

Comprehensive Panel 18.50

Lipid Profile 35.00

CBC with Differential 14.50

Beta 2 Microglobulin 71.50

Liver Panel (Alk PO4, SGOT, SGPT and GGTP) 78.00

Benzene (Blood) 33.00

Lead/ZPP 35.00