Amendment 0001 Performance Work Statement_10MAR20.pdf

PDF 262 KB Posted Mar 10, 2020

Attached to: OKNG ANNUAL OCCUPATIONAL MEDICAL
Solicitation number: W912L6-20-R-0007
Issued by: Department of the Army National Guard

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File	Type	Posted
Amendment 0001 Combined Synopsis and Solicitation_10Mar20.pdf	PDF	Mar 10, 2020
Amendment 0001 Changes Summary_10MAR20.pdf	PDF	Mar 10, 2020
NEWUPDATEDPERFORMANCE WORK STATEMENT OCC Health Exams REVISED 15 JAN 2020.pdf	PDF	Feb 20, 2020
Mock Pricing Scenerio Sheet.DOCX	DOCX document	Feb 20, 2020
Proposal Pricing Sheet.docx	DOCX document	Feb 20, 2020
Occupational Health Combined Synopsis and Solicitation.pdf	PDF	Feb 20, 2020

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PERFORMANCE WORK STATEMENT

OKNG ANNUAL OCCUPATIONAL MEDICAL

SURVEILLANCE EXAMINATIONS

1. Purpose. The purpose of the Occupational Medical Surveillance Examination Program is to provide job-related Medical Surveillance Examinations and Occupational Health Services to the Oklahoma National Guard (OKNG) full-time support (FTS) and/or temporary personnel who are or potentially could be exposed to health hazards in the work environment. The examination shall include personnel assigned to positions requiring specific standards of physical fitness.

2. Blanket Purchase Agreement. This multiple award Blanket Purchase Agreement (BPA) is established by the OKNG to fulfill a requirement for occupational medical surveillance examinations. Under a BPA, the Government is obligated only to the extent of authorized purchases actually made under the BPA. No minimum guarantee quantity or dollar amount is included. The master BPA will not obligate any funds. Funds will be obligated by the individual Calls made against this master BPA.

The Government’s intent is to have a clinic facility in the Oklahoma City area, and Tulsa area.

The Government has reserved the right to award one or two BPAs to provide this coverage.

This Agreement is not exclusive for the period or region for services stated. This BPA is intended to support employees throughout the state of Oklahoma, but may, based on the needs of the Government and the discretion retained by the Government, be used to support other regions or may not be used at all.

3. Contract Line Items and Pricing. Contract Line Items (CLINs) and pricing for a base period and each option periods will be set forth in the Pricing Schedule included in the final blanket purchase agreement.

4. Contractor’s Maximum Capacity. Contractor’s maximum capacity that can be examined daily is eight (8). Contractor’s maximum capacity that can be examined monthly is one hundred sixty (160).

5. Period of Performance. This BPA is for a base period of two (2) years and contains three (3) one year option periods which may be exercised at the Government’s sole discretion.

6. Objectives.

a. To identify a contractor that has a fixed facility from which to conduct these examinations located in either the Oklahoma City metro area, the Tulsa metro area, or both. This specific solicitation is not looking for many versions of mobile solutions that could be available to fulfill this contract, due primarily to the lack of flexibility with scheduling that could occur with many of our shops across the state, the potential limited number of days that would be available to conduct exams, and the risk of compromise to calibration of audiometric equipment or inability to re-certify audiometric standards in multiple testing areas after movement of the equipment.

b. To monitor the health of hazard-exposed workers to determine if work-related problems are or have occurred in accordance with legal and federal regulatory requirements.

c. To ensure compliance with DoD 6055.5-Manual, “Occupational Medical Surveillance

Manual”, which provides minimum standards for occupational examination protocols and medical monitoring (e.g., Pre-placement/Baseline, Periodic & Termination/Retirement Exams) to include verification that:

i. Requirements for medical surveillance, examination types, and record keeping are met.

ii. Mandatory occupational medical examination requirements of Occupational Safety

& Health Administration (OSHA) Standard of Air Contaminants, 29 CFR 1910.1000.

iii. Additional medical surveillance protocols endorsed by the Department of Defense

(DoD) where OSHA does not provide clear specific guidance are implemented.

7. Applicable Regulations and References. Services, examinations, documentation, and reports provided by Contractor shall comply with the following references and regulations:

a. Title 29, Code of Federal Regulations (CFR), Part 1910 Occupational Safety and Health

Administration, Labor.

b. DoD 6055.05-M “Occupational Medical Examinations and Surveillance Manual”, 31 Aug

2018.

c. DoDI 6055.05 “Occupational and Environmental Health (OEH)”, 31 August 2018.

d. DoDI 6055.01, “DoD Safety and Occupational Health (SOH) Program,” 14 October 2014.

e. AR 40-501 Standards of Medical Fitness, 27 June 2019.

f. AR 40-5 Preventative Medicine, 25 May 2007.

g. National Guard Supplement 1 to AR 385-10, The Army Safety Program, 12 February 2015.

h. American National Standards Institute, Inc. (ANSI A-88.6) Respiratory

Protection/Respirator Use: Physical Qualifications.

i. US Army Industrial Operations Command, Command Surgeon’s Team, Occupational

Health Guide to Program Management, July 1999.

j. HIPAA

k. Privacy Act

l. OSHA & ADA

8. Examination Requirement. The Contractor shall provide all labor, materials, and equipment necessary for performance of individual examinations onsite at Contractor’s facility upon request of the OKNG. Scheduling of exams shall be accomplished by coordination between the Contractor, individual to be examined, and the COR. Pre-placement examinations shall be scheduled not more than 3 business days from the date the request is made. Other examinations shall be scheduled not more than 20 business days from the date the request is made.

Examinations shall be scheduled over a period of one year on a rotational system managed by the COR. Contractor shall provide ahead of the exam process, a complete set of all forms to be utilized for the Physical Exam for the purpose of review for any possible editing requirements to meet the needs of the Government and for early distribution to the scheduled employees to complete ahead of the exam process. Examinations shall consist, at a minimum, of the following:

a. Medical Examination. Contractor shall perform a comprehensive medical exam, which shall include but should not be limited to the items set forth in the Panels 1 through 5.

b. Test Panels. Contractor shall provide one of the five Test Panels to each individual to be examined. The test panel required for a particular individual shall be determined by the individual’s job and workplace health hazards, and will be indicated by the COR at the time the examination is scheduled. Panels one through five are further defined in Exhibit “1”.

c. Hearing Examination. Audiometric Test at 500, 1000, 2000, 3000, 4000, and 6000 dB.

If Contractor is, “Defense Occupational Environmental and Health Readiness System- Hearing Conservation (DOEHRS-HC) Computer Program Capable, proper forms will be utilized, i.e., for base line hearing exams, DD Form 2215, for subsequent hearing exams following a documented baseline, form 2216 will be utilize. If not DOEHRS Capable, provider will document hearing results on AUDIOGRAM (Hearing Test) form provided within the exam packet. A Hearing Booth or Sound Proof Room is required in which to conduct the hearing test. Whisper Testing is not allowed.

d. Counseling, Documentation, and Results. Results and Findings shall include, at a minimum, the following Documentation and Test Results (Documents for Standard Forms referenced below shall be provided to Contractor in electronic form following award).

Forms may be updated by the Government from time to time. Electronic copies of revised forms shall be provided to Contractor as available. Contractor shall use the most recent version of revised forms provided.

iv. DD Form 2807-1, OCT 2018 - Report of Medical History to be completed by the individual Applicant/Employee and reviewed by physician prior to the hands on physical exam.

v. DD Form 2808, JUL 2019 – Report of Medical Examination Physical Findings - to be completed by technician, nurse and the examining physician.

vi. Respirator Questionnaire - To be completed by those employees who are required to wear a Respirator/Mask and need to be Fit Testing, and will meet current OSHA requirements. The Contracted Medical Providers will draft a, “Respiratory Medical Clearance” letter on their appropriate letter head for each employee who is Fit Tested, two copies will be mailed, one to the employee who received a Fit Test who will provide a copy to his or her work site supervisor. Second copy will be mailed or emailed to the OKARNG Occupational Health Nurse. (Example of said letter will be provided).

vii. Hearing Conservation Examination Form – Employee will complete the first page of the form, and the Examiner will complete the rest. Audiometric reports must contain:

a) The examiner’s name, Title and CAOHC (Council for Accreditation in

Occupational Hearing Conservation) certification number as appropriate.

b) The reviewer’s name (audiologist or physician and or Technician), certification number, or the Government equivalent civilian job code (e.g.

0665-Audiologist)

c) The make, model, serial number and the most recent electro acoustic calibration date of the audiometer used.

d) Contractor shall, prior to the contract test date, provide documented proof of each audiometers last calibration date in accordance with the ANSI S3.6-1996 standard. The calibration date must be within less than one year of contract test examinations.

e) Contractor will ensure that hearing testing performed, will be accomplished in a quiet area away from obvious ambient noise, sound proof booth and or room is preferred. If test results are questionable, and or a high ratio of loss or shifting presents, repeat hearing testing will be accomplished by the Contractor at no additional fee.

viii. Lab Results – Copy of any lab results performed attached to completed exam.

ix. Summary Letter of Findings - Contractor shall provide a typed cover letter to the individual, summarizing findings of the examination and test results. Each letter shall be customized and will summarize in lay terms the individual’s test results along with a recommendation as warranted by the results for the individual to follow up with their personal physician as indicated. Contractor shall provide a copy of the same letter to the Government. At the discretion of the Contractor, a disclaimer may be added to the exam cover letter stating, “If you require further information, or have questions related to the exam results, you are welcome to reply within thirty days of receipt. If no response we presume you acknowledge receipt and accept the results as stated.” A checklist method to disseminate test results is not acceptable. Contractor shall provide a full copy of other documentation or results to the individual examined upon request at no additional charge to the Government or the individual.

x. Counseling by Examining Physician – During the initial examination, any acute findings or areas of concern should be discussed by the examining physician with the individual.

9. Delivery of Documentation and Results. All completed results, forms, and documentation for examinations and lab results shall be transmitted to COR/State Occupational Health Nurse within 15 business days of the appointment. Contractor may either mail paper copies or e-mail results to the State Occupational Health Nurse. One copy shall be provided to the OKNG Occupational Health Nurse and one copy shall be mailed directly to the individual employee’s home of record. Any paper copies provided in bulk to the Occupational Health Nurse shall be sent in appropriately secured, correctly sized individual envelopes that allow for the records to be transmitted without being folded. Each employee’s records sent to the State Occupational Health Nurse shall be in separate envelopes, which shall be identified on its exterior with the employee’s full name, job code, and work location on the front of the sealed envelope. Records mailed in bulk shall be packaged in Alphabetical order, and if stapling is required; documents will be stapled in the upper left hand corner, at a minimum. Medical examination results shall include all diagnostic tests, graphs, charts, reports, questionnaires, waivers, employee consent forms, physical findings, and examination results. Results of medical surveillance testing, which are questionable and / or of critical significance shall be communicated directly and immediately to the Contracting Officer Representative (COR) by telephone, email, or express mail as soon as possible. Secure emailing of urgent results is acceptable, but not ahead of communication via phone first.

10. Statistical Data Analysis and Summary of Results. Statistical Data Analysis and Summary of Results shall include, at a minimum, the following: Annually, at a date to be determined by the Government, the Government may request Contractor provide a comprehensive data processed analytical end report in a binder (or on CD in excel spreadsheet format) for all OKNG Full Time Employees who received Exams during the year. Pricing for services provided herein for Statistical Data Analysis and Summary of Results shall be on a firm fixed price basis at the rate set forth in the Blanket Purchase Agreement. Contractor shall summarize, provide basic trending and statistical analysis, divide and present, at a minimum, the following information and results:

a. Tab # 1 – Respiratory Fit Test Summary to include, Colum # 1 – The tested

Employee Name, Colum # 2 – last 4 of SSN, Colum # 3 – Test Date, Colum # 4 – Type of Respirator, Colum # 5 - Result - P = Pass, F = Fail, TNP = Test Not Performed,

b. Tab # 2 – Employee Listing with Hearing Classifications to include, Colum # 1

Employee Name, Colum # 2 last 4 of SSN, Colum # 3 Date, Colum # 4 – Hearing status (Normal, Mild Hearing Loss, Moderate Hearing Loss, Moderate Severe Hearing Loss, and Profound Hearing Loss), Colum # 5 – Significant Threshold Shift (Yes or No)

11. Changes to Test Panels, Documentation, or other Requirements. Government may request reasonable changes within the scope of this agreement to Test Panels, forms used, format of results, and other services or deliverables as required for regulatory compliance, changing job descriptions, or other needs of the Government. Contractor shall work with the Government and accommodate such changes, but may negotiate for compensation for changes in services within the scope of the resultant Blanket Purchase Agreement if additional costs will be incurred as a result of the requested changes. No changes shall be made except by written modification to a BPA or BPA Call that is duly executed by the Contracting Officer.

12. Referral for Follow-Up Assessment or Treatment. Contractor shall refer individuals to their primary care physician for follow-up assessments, if needed, and for treatment or care of any conditions identified. The scope of services provided for hereunder are for individual assessment and data analysis only. Treatment is not provided for herein. Should the individual examined desire to obtain care or treatment from the Contractor, and the Contractor desires to provide such services, all services not specifically provided for hereunder shall be provided at the individual’s expense and at the Contractor’s sole risk.

13. Credentials of Examiners and Physicians.

Examinations and testing shall be performed by appropriately licensed and or certified professionals. Panel requirement, results, reports, opinions and summary letters shall be accomplished by a licensed physician who is, (1) Preferably Board Certified in Occupational Medicine or, (2) a doctor of osteopathy, (3) a doctor who has experience in Occupational Health , or a Registered Nurse Practitioner RNP with five or more years of occupational health or industrial hygiene specific experience. If unable to provide a Board Certified or Board Eligible physician, the examining physician will have documented education and training in Occupational/Industrial Health as outlined within OSHA Guidance. Review shall be annotated by said physician’s endorsement, certification, or acknowledgement on the document prior to transmission to the OKNG. Contractor shall, as a condition of contract Award, and as a condition of exercise of options on an annual basis, or more frequently upon request, provide copies of applicable current credentials for medical providers who will be conducting these examinations.

14. Credentials of Technicians. Contractor shall ensure licensed/certified medical technicians perform the Medical Surveillance Examination screening/testing elements. The medical surveillance person(s) to operate the audiogram should be certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC). Personnel conducting Spirometry should be certified through a program approved by the National Institute for Occupational Safety and Health (NIOSH). Each Medical Professional conducting any Exam Panel Testing will possess the appropriate certification and or licensure and will produce documentation of said certifications and or licensure documents as requested.

15. Compliance of Facility, Operations, Examination and Testing Procedures. 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. Contractor is solely responsible for identification and compliance with any and all applicable regulations, including but not limited to federal, state, and local statues for all services provided pursuant to each BPA Call.

16. Compliance of Laboratory Services. 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/or the College of American Pathologies, and/or certified in Clinical Laboratory Improvement Amendment (CLIA) testing, and/or certified by the Center for Medicare and Medicaid Services (CMS) for any diagnostic testing. Contractor shall, as a condition of contract award and as a condition of exercise of options on an annual basis, or more frequently upon request, provide proof that their laboratory meets this requirement.

17. Follow-Up Telephone Consultation. Contractor shall provide as part of the examination services hereunder, at no additional charge to the Government, for the opportunity to consult with representative of the OKNG by telephone to coordinate or resolve issues that might arise before, during, and after the testing period. This will be a Work Supervisor of the employee in question and or the OKNG Occupational Health Nurse.

18. Government Furnished Equipment. No Government Furnished Equipment or Services are identified as part of this requirement. Government will furnish the information and forms set forth above to the Contractor in support of Contractor’s Examinations. Forms may be updated from time to time with the concurrence of the Contractor, the COR, and the Contracting Officer without the need for a contract modification.

19. Privacy Act Statement. Contractor shall be provided the Privacy Act Statement (DD Form

2005 or the facilities own version of that form) for each employee to sign during the registration process, should employees be instructed to complete a release form by Contractor in order to authorize release of examination, testing, or lab results to the Government. In addition, all examinees shall complete a Release of Information Authorization upon arrival to the clinic prior to completion of their Physical exam to acknowledge permission to release examination results and information back to the Government as the examinee's employer.

20. Calibration or Certification of Equipment. Certification or calibration shall demonstrate that equipment is currently compliant with industry standards. In the event that laboratory or testing results are questionable due to deviations from other tests on file or potential equipment or facility problems, repeat testing will be accomplished by the Contractor at no additional charge to the Government. Contractor shall ensure instrumentation meets or exceeds appropriate performance standards, and accuracy must be verified in accordance with current Occupational Medicine Certification standards. Proof of calibration or certification should be provided at a minimum on audiology equipment / systems (completed at least annually) and for Pulmonary Functions Testing equipment / systems (varies). Contractor shall, as a condition of contract Award, and as a condition of exercise of options on an annual basis, or more frequently upon request, provide documented proof of certification or calibration of Audiology and Spirometry medical equipment used for testing and examination described herein.

21. Insurance Requirements. As a condition of contract award and as a condition of exercise of options on an annual basis, or more frequently upon request, the contractor will provide proof of liability and medical malpractice insurance.

22. Indemnification by Contractor. 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. Contractor shall maintain, and shall be responsible for ensuring all subcontractors maintain, insurance equal to or greater than the requirements set forth in FAR Clause 52.237-7.

23. Limitation on Sub-Contracting. Contractor shall provide 51% or more of all services, and may not sub-contract more than 49% of services provided to the government for any given BPA Call. Contractor shall provide the government with a list of sub-contractors who are providing services to Government’s employees. Contractor is solely responsible for compliance of all sub-contractors with the requirements of the Blanket Purchase Agreement.

24. Quality Assurance. Contractor shall develop, implement, and maintain a comprehensive quality control program that assures compliance with all requirements of this contract and its associated BPA Calls. Contractor shall maintain, enforce, and document a Quality Control Plan (QCP). The QCP shall ensure that the Government receives the level of quality that is consistent with the requirement s specified in each BPA Call. Reference FAR clause 52.246- 4, Inspection of Services – Fixed Price. The OKNG shall maintain a separate quality assurance surveillance program and shall monitor the delivery of goods and services provided for under the resultant BPA. Acceptable Quality Levels (AQL) and Quality Assurance Surveillance Plan (QASP) for the Government are set forth in Exhibit “2”. The QASP may be revised or updated by the Government, from time to time, as needed to ensure monitoring and delivery of required elements under the Contract. Contractor shall be provided a copy of any modified or revised

QASP.

25. Contract Manager. 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 on site at all times during the performance of services.

26. Travel. Travel by Contractor is not contemplated by the Government as part of the requirement set forth herein. In the event that travel is required, transportation and travel or travel related expenses are the sole responsibility of the contractor and are not payable or reimbursable by the OKNG absent a modification to the contract by the Contracting Officer authorizing payment.

27. Non-Personal Services. 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.

EXHIBITS

Exhibit “1”

Panel Definitions

PRIMARY CLIENT OKLA ARMY NATIONAL GUARD

CLIENT: Oklahoma Army National Guard

3501 Military Circle Oklahoma City, OK 73111

CONTACT: Mr. Rustin Wonn Occupational Health Nurse

(405) 228-5602 Email: rustin.k.wonn.civ@mail.mil

PROVIDER: (Location & Contact)

TEST PANEL: 01

(Annual - DOES Use Respiratory Protection)

Employee Name and Work Location:____________________________________________________ Date:________________________

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

Fasting: Standard - As needed

Medical Release of Information : DD Form 2870 (DEC 2003) “Authorization for Disclosure of Medical Information”

History: Confidential DD Form 2807-1 OCT 2018 Report of Medical History Questionnaire, to include respiratory history for P.P.E. (MASK) wearers. (or equivalent)

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

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

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation Audiogram Hearing Health History and Test Form Respiratory History (OSHA Compliant) Respirator Fit Test Qualification – Protocol Respiratory Medical Clearance Letter Report of Medical History DD Form 2807 – 1, OCT 2018 (or equivalent) Report of Medical Examination DD Form 2808, JUL 2019 (or equivalent)

Physician’s Examination of the Record (and Lab Results if applicable)

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

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

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

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

Chest X-Ray: N/A or if Spirometry abnormal or if indicated by physician

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

MD Exam: Physician hands-on exam (EKG OPTIONAL as determined by Physician)

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

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

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

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

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

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

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

Comparative Data: Accomplished by provider of services Respirator Clearance Letter: Accomplished by Medical Provider

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

Type of Tube(s) As Needed

Test(s) Order Lab Panel # Special Instructions

TBD

Lab tests to be agreed upon between Provider and OKARNG OHN

Urine Chromium for PAINTERS and WELDERS ONLY

TEST PANEL: 02

(Annual - DOES NOT use Respiratory Protection)

Employee Name and Work Location:___________________________________________________

Date:_______________________ Corporate Consent: Yes. (To Occupational Health Nurse of Oklahoma Army National Guard.)

Fasting: Standard – As Needed

Medical Release of Information : DD Form 2870 (DEC 2003) “Authorization for Disclosure of Medical Information”

History: Report of Medical History Questionnaire DD Form 2807-1, OCT 2018 (or equivalent)

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

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

Service Years: Number of years performing Wage Grade Job:

Special Forms: Hearing Conservation Audiogram Hearing Health History and Test Form Report of Medical History DD Form 2807 – 1, OCT 2018 (or equivalent) Report of Medical Examination DD Form 2808 – JUL 2019 (or equivalent) Physician’s Examination of the Record (and Lab Results if applicable)

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

Temperature & Respirations: Standard Record results on Medical Examination Record

Audiometry: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth or soundproof room Required.

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

Chest X-Ray: N/A or if Spirometry abnormal or if indicated by physician

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

MD Exam: Physician hands-on exam (EKG OPTIONAL as determined by Physician)

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

Quantitative Fit Testing: Not Required

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

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

Spirometry: Not Required

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

Comparative Data: Accomplished by provider of services

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

Needed

Test(s) Order Lab Panel # Special Instructions

TBD

Lab tests to be agreed upon between Provider and

OKARNG OHN

TEST PANEL: 03

(Pre-Placement Exam)

Corporate Consent: Yes. (To Occupational Health Nurse of OKARNG)

Fasting: Standard – As Needed

Medical Release of Information : DD Form 2870 (DEC 2003) “Authorization for Disclosure of Medical Information”

History: Report of Medical History DD Form 2807-1 OCT 2018 (Or equivalent)

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

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

Service Years: Number of years military service:

Special Forms: OF 178 (DEC 2014) “Certificate of Medical Examination” Hearing Conservation - Audiogram Hearing Health History and Test Form Report of Medical History Report of Medical Examination

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

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

Audiometry: Test Only (500, 1000, 2000, 3000, 4000, 6000 Hz) - Hearing Booth or Soundproof room Required.

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

Chest X-Ray: N/A or if Spirometry abnormal or if indicated by physician

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

MD Exam: Physician hands-on exam (EKG OPTIONAL as determined by Physician)

Quantitative Fit Testing: Client will bring his or her Mask for Fit Testing – Masks generally utilized are

– 3M 6100 -Half Face, 3M 6200 - Half Face, 3M6300- Half Face, and 3M 7800 – Full Face Mask

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

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

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

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

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

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

Respirator Clearance Letter: Accomplished by Medical Provider

TEST PANEL: 04

Change of Hazard / End of Hazard – Does Use Respiratory Protection

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

Fasting: Standard - As needed

Medical Release of Information : DD Form 2870 (DEC 2003) “Authorization for Disclosure of Medical Information”

History: Confidential DD Form 2807-1 OCT 2018 Report of Medical History Questionnaire, to include respiratory history for P.P.E. (MASK) wearers. (or equivalent)

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

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

Service Years: Number of years performing Wage Grade Job:

Physician’s Examination of the Record (and Lab Results if applicable) Physicians Summary Letter will specify Type of Exam