PWS Occupational Health Medical Lab Exams.pdf

Ver. December 2020

PERFORMANCE WORK STATEMENT (PWS)

FOR

Occupational Health Medical Examinations

1.0 General:

1.1 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 required Occupational Medical Examinations: Medical Surveillance exams and Medical Qualification exams, as defined in both this PWS and in DoD Manual 6055.05 “Occupational Medical Examinations:

Medical Surveillance and medical Qualification”, dated Change 1 on April 5, 2024.

1.2 Background: 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 Occupational Safety and Health Administration (OSHA) sets the basic requirements for these exams.

1.3 Period of Performance (PoP): The Period of Performance shall be an ordering period of five years.

1.4 General Information:

1.4.1 Place and Performance of Services: The contractor shall provide services between the hours of 0800-1600 on Monday through Friday, except on recognized US holidays or special company event days.

The contractor shall always maintain an adequate work force 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 the work force are essential.

1.4.1.1 It is the government’s intent to identify a contractor(s) 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 areas. 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.

1.4.1.2 Telework: These required services are not able to be accomplished through telework.

1.4.1.3 The contractor will rarely be required to visit one of our facilities. It is expected that the contracted services will occur at the contractor’s facility.

1.4.2 Recognized Holidays: The following are recognized United States (US) holidays. The contractor shall not be expected to perform services on these days:

1.4.2.1 New Year’s Day: January 1st

1.4.2.2 Martin Luther King, Jr.’s Birthday

1.4.2.3 President’s Day

1.4.2.4 Memorial Day

1.4.2.5 Juneteenth

1.4.2.6 Independence Day: July 4th

1.4.2.7 Labor Day

1.4.2.8 Columbus Day

1.4.2.9 Veteran’s Day: November 11th

1.4.2.10 Thanksgiving Day

1.4.2.11 Christmas Day: December 25th

1.4.3 Quality Control (QC): The contractor shall develop and maintain an effective QC Plan (QCP) to ensure services are performed 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 QCP is how it assures itself that its work complies with the requirements of the contract. As a minimum, the contractor shall develop QC procedures that address the areas identified in Technical Exhibit “2”, Performance Requirements Summary (PRS).

1.4.4 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 will 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) or defect rate(s). Acceptable Quality Levels (AQL) and Quality Assurance Surveillance Plan (QASP) for the Government are set forth in Technical Exhibit “4”. 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.

1.4.5 Installation Access and Security Requirements. The contractor should rarely need to visit our state and federal facilities. If that is scheduled the contractor shall comply with all applicable installation/facility access and local security policies and procedures, which may be obtained from the Contract Officer Representative (COR). The contractor and all employees shall provide all information required for background checks to meet installation access requirements to be accomplished by installation Provost Marshal Office, Director of Emergency Services, or Security Office.

1.4.5.1 For contractors that do not require a Common Access Card (CAC), but do require access to a DoD facility or installation: Contractor and all associated sub-contractors employees shall comply with adjudication standards and procedures using the National Crime Information Center Interstate Identification (NCIC-III) and Terrorist Screening Database (TSDB) (Army Directive 2014-05), and applicable installation, facility and area commander installation/facility access, and local security policies and procedures (provided by a Government representative).

1.4.5.2 Communications Security/Information Technology (COMSEC/IT) Security. All communications with DoD organizations are subject to COMSEC review. All telephone communications networks are continually subject to intercept by unfriendly intelligence organizations. DoD has authorized the military departments to conduct COMSEC monitoring and recording of telephone calls originating from, or terminating at, DoD organizations. Therefore, the contractor is advised that any time contractor personnel place or receive a call they are subject to COMSEC procedures. The contractor shall ensure wide and frequent dissemination of the above information to all employees dealing with DoD information.

The contractor shall abide by all Government regulations concerning the authorized use of the Government's computer network, including the restriction against using the network to recruit Government personnel or advertise job openings.

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

1.4.6 Physical Security. The contractor shall safeguard all Government property provided for contractor use and all electronic and paper copies of PII and medical records. At the close of each work period facilities, equipment and materials shall be secured.

1.4.7 Special Qualifications: The contractor shall ensure all employees possess all required licenses and training for operating all medical equipment or devices used in the performance of this contract. This does not include education or other qualifications for the position in which the contractor employee is performing, dress codes, or other information. (NOTE: The Government does not provide training to contractors. Contractors must ensure that any personnel performing under a contract are fully trained, licensed, certified, and qualified to provide services.)

1.4.8 Post Award Conference/Periodic Progress Meetings: The contractor agrees to attend any post award conference convened by the Contracting Officer (KO) in accordance with FAR 42.5. The KO, COR and other Government personnel, as appropriate, may meet periodically with the contractor to review the contactor’s performance. At these meetings, the KO 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 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. The Contract Manager and the government’s Contract Officer Representative should meet quarterly, either in person or via telecommunication, to ensure the ongoing satisfaction of both parties and to address any areas of concern by either party.

1.4.10 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. 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.

2.0 Definitions and Acronyms:

2.1 Definitions:

2.1.1 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.

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

2.1.3 Deliverable: Anything that can be physically delivered and includes non-manufactured things such as meeting minutes or reports.

2.1.4 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 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.

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

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

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

2.1.8 Quality Control: All necessary measures taken by the Contractor to ensure that the quality of a product or service shall meet contract requirements.

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

2.2 Acronyms:

AEI Army Enterprise Infostructure AR Army Regulation AT/OPSEC Antiterrorism/Operational Security BI Background Investigation CAC Common Access Card (military ID) CM Contract Manager COMSEC Communications Security COR Contracting Officer Representative DA Department of the Army DD254 Department of Defense Contract Security Classification Specification DFARS Defense Federal Acquisition Regulation Supplement DoD Department of Defense FAR Federal Acquisition Regulation FTS Full Time Support Personnel GFP/M/E/S Government Furnished Property/Material/Equipment/Services HQDA Headquarters, Department of the Army HSPD Homeland Security Presidential Directive IA Information Assurance IS Information System(s) KO Contracting Officer KO Contracting Officer NCIC-III National Crime Information Center Interstate Identification NGB National Guard Bureau OCI Organizational Conflict of Interest OKNG Oklahoma National Guard OSHA Occupational Safety and Health Agency PII Personally Identifiable Information PIPO Phase In/Phase Out POC Point of Contact PoP Period of Performance PRS Performance Requirements Summary PWS Performance Work Statement QA Quality Assurance QASP Quality Assurance Surveillance Plan QC Quality Control QCP Quality Control Plan SCR Service Contract Reporting SSN Social Security Number TE Technical Exhibit TSDB Terrorist Screening Database USD(I) Under Secretary of Defense for Intelligence

3.0 Government Furnished Property, Material, Equipment and Services (GFP/M/E/S): The Government will provide the property, material, equipment, and/or services listed below solely for the purpose of performance under this contract:

3.1 Property: The Government will not furnish any specific materials, equipment, property, or services in fulfillment of this requirement.

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

4.1 General: Except for those items specifically stated to be Government-Furnished in Paragraph 3.0, the contractor shall furnish all property, materials, and equipment required to perform these services as indicated in Paragraph 1.1.

5.0 Requirements: The contractor shall:

5.1 The Contractor shall provide all labor, materials, and equipment necessary for performance of individual examinations onsite at Contractor’s facility upon request and scheduling of the OKNG.

Scheduling of exams shall be accomplished by coordination between the Contractor, individual to be examined, and the COR. Medical Qualification examinations shall be scheduled not more than 10 business days from the date the request is made (it is usually more time sensitive for our organization to ensure potential employees are qualified for positions to expedite the hiring process), and the requests for these examinations should not exceed 2 requests per week. All other types of examinations shall be scheduled not more than 15 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 components:

5.1.1 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 6.

5.1.2 Test Panels. Contractor shall provide exams based on one of the six Test Panels to everyone 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 or employee at the time the examination is scheduled. Panels one through six are further defined in Exhibit “1”.

5.1.3 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. Contractor will identify an individual to become DOEHRS Capable, this individual will upload all hearing test results into the Defense Occupational and Environmental Health Readiness System-Hearing Conservation (DOEHRS-HC) online program. The 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. Proof of annual calibration will be required.

5.1.4 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.

5.1.4.1 DD Form 2807-1, OCT 2018 - Report of Medical History (or comparable and acceptable clinic form) to be completed by the individual Applicant/Employee and reviewed by physician prior to the hands-on physical exam.

5.1.4.2 DD Form 2808, JUL 2019 – Report of Medical Examination Physical Findings (or comparable and acceptable clinic form) to be completed by technician, nurse, and the examining physician.

5.1.4.3 Respirator Questionnaire - To be completed only by those employees who are required to wear a Respirator/Mask and need to be Fit Tested, and form 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. One copy will be mailed or emailed to the employee receiving the fit testing, 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 can be provided).

5.1.4.4 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, soundproof 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.

f) Contractor will provide hearing education: a written handout, and verbal explanation to ensure that the employee is adequately informed of the causes and risks of noise induced hearing loss.

g) Contractor will demonstrate proper insertion of hearing protection devices and ensure that employees are comfortable and competent in the correct method of inserting hearing protection.

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

5.1.4.6 Summary Letter of Findings - Contractor shall provide a typed cover letter to the Occupational Health Nurse and/or employee, 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 all other documentation or results to the individual examined upon request at no additional charge to the Government or the individual.

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

5.2 Delivery of Documentation and Results. A copy of all completed results, forms, and documentation for examinations and lab results shall be transmitted to the 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. Medical examination results shall include all diagnostic tests, graphs, charts, reports, questionnaires, waivers, employee consent forms, physical findings, and examination results. All exam documentation shall be legible, with all data accurate, pertinent, and pertaining only that employee. 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) or Occupational Health Nurse (OHN) 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.

5.3 Statistical Data Analysis and Summary of Results. This document will be an “Annual Rollup” of Statistical Data Analysis and Summary of Results shall include, at a minimum, the following: Annually, on the first day of October, the Government may request Contractor provide a comprehensive data processed analytical end report in a binder, or on CD in excel spreadsheet format, or on Access 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:

-Employee Name (Last Name First) -Last 4 of SS# -Date of Exam -Type of Exam conducted -Respiratory Fit Test Completed (yes/no) and (passed / failed) -Respiratory Medical Clearance Completed (yes/No) and (passed / failed) -Type of Respirator Used

-Employee Hearing Status (normal, mild hearing loss, moderate hearing loss, moderate to severe hearing loss, or profound hearing loss).

-Did the Employee have a Significant Threshold Shift in Hearing (yes/no)

5.4 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 because 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.

5.5 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 receiving the examination 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.

5.6 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 or Physicians Assistant PA with two or more years of occupational health or industrial hygiene specific experience. If unable to provide a Board Certified or Board Eligible physician, the examining provider will have documented education and training in Occupational/Industrial Health as outlined within OSHA Guidance.

Review shall be annotated by said providers 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.

5.7 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), or equivalent. 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 licensure and will produce documentation of said certifications and or licensure documents as requested.

5.8 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.

5.9 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.

5.10 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 may be a Work Supervisor of the employee in question and or the OKNG Occupational Health Nurse.

5.11 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.

5.12 Privacy Act Statement. Contractor shall be provided the Privacy Act Statement (DD Form 2005 or the facilities may use their 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 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.

5.13 Calibration or Certification of Equipment. Certification or calibration shall demonstrate that equipment is currently compliant with industry standards. If 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.

5.14 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.

5.15 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.

5.16 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.

5.17 Travel. Travel by Contractor is not contemplated by the Government as part of the requirement set forth herein. If 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.

5.18 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 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.

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

Publication (Chapter/Page)

Date of Publication

Mandatory or Advisory

Website

Federal Acquisition Regulation Online updated

M https://www.acquisition.gov/?q=browsefar

Defense Federal Acquisition Regulation Supplement

Online updated

M http://www.acq.osd.mil/dpap/dars/dfarspgi/current/in dex.html or https://www.acquisition.gov/dfars

Joint Travel Regulation (JTR) Online updated

A https://www.defensetravel.dod.mil/site/travelreg.cfm

DoDM 1000.13-M-V1 DoD Identification (ID) Cards

01/23/2014 A http://www.esd.whs.mil/Directives/issuances/dodm

(Enclosure 2, paragraph 3.b) (Change 1:

07/28/2020)

DoDM 5200.2 Procedures for the DoD Personnel Security Program

(PSP)

04/03/2017 A https://www.esd.whs.mil/Directives/issuances/dodm/

DoDI 5200.46 DoD Investigative and Adjudicative Guidance for Issuing the Common

Access Card (CAC)

09/09/14 (Change 1:

05/04/2018)

A https://www.esd.whs.mil/Directives/issuances/dodi/

Homeland Security Presidential Directive (HSPD)-12

Policy for a Common Identification Standard for Federal Employees and

Contractors

08/27/2004 A https://www.dhs.gov/homeland-security-presidential-directive-12

DoDI 5400.11 Department of Defense Privacy and

Civil Liberties Programs

01/29/2019

A https://www.esd.whs.mil/Directives/issuances/dodi/

DoD 5400.11-R Department of Defense Privacy

Program

05/14/2007 M https://www.esd.whs.mil/Directives/issuances/dodm/

DoDD 8140.01 Cyberspace Workforce Management

10/05/2020

M https://www.esd.whs.mil/Directives/issuances/dodd/

DoD 8570.01-M Information Assurance Workforce

Improvement Program

12/19/2005 (Change 4:

11/10/2015)

A https://www.esd.whs.mil/Directives/issuances/dodm/

DoD 5220.22-M National Industrial Security Program

Operating Manual (NISPOM)

02/28/2006 (Change 2:

05/18/2016)

A https://www.esd.whs.mil/Directives/issuances/dodm/

Army Directive 2014-05 Policy and Implementation

Procedures for Common Access Card Credentialing and Installation Access for Uncleared Contractors

03/07/2014 A https://armypubs.army.mil/ProductMaps/PubForm/A rmyDir.aspx

AR 25-2

Information Assurance

04/04/2019

A http://armypubs.army.mil/ProductMaps/PubForm/AR .aspx

AR 530-1

Operations Security

09/26/2014 A http://armypubs.army.mil/ProductMaps/PubForm/AR .aspx

AR 525-13

Antiterrorism

12/09/2019 A http://armypubs.army.mil/ProductMaps/PubForm/AR .aspx

AR 381-12

Threat Awareness and Reporting

Program (TARP) (Section II, ¶ 2-4.b)

06/01/2016 A http://armypubs.army.mil/ProductMaps/PubForm/AR .aspx

DOD Manual 6055.05 Occupational Medical Examinations:

Medical Surveillance and Medical Qualification

7/27/2022 Change 1:

4/5/2024

M https://www.esd.whs.mil/Directives/issuances/dodm/

Executive Order on Combating Race and Sex Stereotyping

09/22/2020 M https://trumpwhitehouse.archives.gov/presidential-actions/executive-order-combating-race-sex-stereotyping/

6.1 Applicable Forms: Forms applicable to the PWS are listed below:

Form Date Website

DD 1172-2

Application for Identification Card/DEERS Enrollment

Mar 2017 http://www.dtic.mil/whs/directives/forms/index.htm

I-9 Employment Eligibility Verification

10/21/2019 https://www.uscis.gov/sites/default/files/files/form/i-9.pdf

DD 441

Department of Defense Security

Agreement

Feb 2020 http://www.dtic.mil/whs/directives/forms/dd/ddforms0001- 0499.htm

DD 250

Material Inspection and Receiving

Report

Aug 2000 https://www.esd.whs.mil/Directives/forms/dd0001_0499/

DD 2215

Reference Audiogram

1/1/2000 https://www.esd.whs.mil/Directives/forms/

DD 2216

Hearing Conservation Data

1/1/2000 https://www.esd.whs.mil/Directives/forms/

DD 2807-1

Report of Medical History

10/29/2019 https://www.esd.whs.mil/Directives/forms/

DD 2808

Report of Medical Examination

7/15/2019 https://www.esd.whs.mil/Directives/forms/

DD Form 2005 Privacy Act Statement – Health

Care Records

6/2016 https://www.esd.whs.mil/Directives/forms/

Technical Exhibit “1”

Test Panel Explanations: The following “Test Panels” are provided to give a more detailed example of the types of exams that we will require for our employees. These panels should be used as a guide to determine which procedures, documents, exams, tests, etc., that should be required for each separate type of panel. They are summarized below, and a more detailed version describing each panel follows this section. It is expected that these are the primary terms that will be used to schedule, conduct, and invoice by each month.

Test Panel 01: This is an annual Medical Surveillance exam for members that ARE currently required to use a Respirator in their position. This would be a standard annual exam, that will include a Respirator Questionnaire, Respiratory Clearance Letter, and Respiratory Fit Test.

Test Panel 02: This is an annual Medical Surveillance exam for members that ARE NOT currently required to use a Respirator. It will be essentially the Same as Panel 01, with no Respiratory tests or documents required.

Test Panel 03: The Medical Qualification Exam is the “pre-placement’ exam that we conduct for employee applicants prior to selecting them or them starting work, that focuses on whether they are medically fit to perform all the physical requirements of the position they are applying for. This is based on the position description, and the physical requirements and working conditions identified for the position. These are not yet full-time employees, they are applicants. It is not expected that we have no more than 1-2 of these new hire exams per week on average.

Test Panel 04: This exam is for employees that are changing job code positions or being promoted.

They are moving out of a position where they did have potential exposures into a position where they will either have different potential exposures, or no exposures at all. This employee does use a respirator in both their current and or future position. This would require notation in the summary letters, to address whether employee has any objective or subjective medical effects from their prior potential exposures.

Test Panel 05: As in test panel 04, this exam is for employees Changing their exposures, Ending their exposures, or Retiring from the organization (Termination Exam). These employees do not use a Respirator. This exam will require notation in the providers summary statements of any obvious or long term health risks based on their prior employment history.

Test Panel 06: This exam is a “Return to Work / Fit for Duty” exam. Some employees that are recovering from injury or illness, or for other reasons unable to perform the physical requirements of their position, will need to be medically evaluated and cleared as able to perform their regular duties, or perform their regular duties with restrictions.

TEST PANEL: 01

(Annual - DOES Use Respirator)

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 clinic equivalent form)

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 current 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 clinic equivalent) Report of Medical Examination DD Form 2808, JUL 2019 (or clinic 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 any time if indicated by provider

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

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

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

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

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

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

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

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

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

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

Type of Tube(s) As Needed Test(s) Order Lab Panel # Special Instructions

TBD

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 Respirator)

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 clinic equivalent) Report of Medical Examination DD Form 2808 – JUL 2019 (or clinic 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 anytime indicated by provider

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

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

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

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

Comparative Data: Accomplished by provider of services annually

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

Type of Tube(s) As Needed Test(s) Order Lab Panel # Special Instructions

TBD

TBD

Lab tests to be agreed upon between Provider and

OKARNG OHN

TEST PANEL: 03

(Medical Qualification 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 clinic 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” or Equivalent Hearing Conservation - Audiogram Hearing Health History and Test Form Report of Medical History Report of Medical Examination Respiratory Fit test and Clearance (only for positions requiring respirator use, small %)

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 any time indicated by provider

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

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

Quantitative Fit Testing: (Limited number of Medical Qualification exams will require Fit Testing) masks usually 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

Comparative Data: Accomplished by provider of services annually

Lab Tests: Only as indicated by provider based on industry standards

TEST PANEL: 04

Change of Hazard / End of Hazard – Does Use Respirator

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 clinic equivalent) Report of Medical Examination DD Form 2808, JUL 2019 (or clinic equivalent)

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

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 provider

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

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

Otoscopic Exam: Standard - Record results on…