DentalAmendment0001.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER (Type or print)

30-105-04EXCEPTION TO SF 30

APPROVED BY OIRM 11-84

STANDARD FORM 30 (Rev. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

A. The purpose of this Amendment is to issue a REVISED RFP. Major elements of the PWS and CLIN structure have changed. Please dow nload the REVISED RFP for use in preparing your proposal.

B. Proposal due date is hereby extended to 28 September 2011at 10:00 AM CST.

1. CONTRACT ID CODE PAGE OF PAGES

J 1 33

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print)

16C. DATE SIGNED

BY 20-Sep-2011

16B. UNITED STATES OF AMERICA15C. DATE SIGNED15B. CONTRACTOR/OFFEROR

(Signature of Contracting Officer)(Signature of person authorized to sign)

8. NAME AND ADDRESS OF CONTRACTOR (No., Street, County, State and Zip Code) X W912LM-11-R-0003

X 9B. DATED (SEE ITEM 11)

14-Sep-2011

10B. DATED (SEE ITEM 13)

9A. AMENDMENT OF SOLICITATION NO.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

X The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offer X is extended, is not extended.

Offer must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended by one of the following methods:

(a) By completing Items 8 and 15, and returning 1 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted;

or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE

RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN

REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS.

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE

CONTRACT ORDER NO. IN ITEM 10A.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(B).

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

10A. MOD. OF CONTRACT/ORDER NO.

2. AMENDMENT/MODIFICATION NO. 5. PROJECT NO.(If applicable)

6. ISSUED BY

3. EFFECTIVE DATE

20-Sep-2011

CODE

DEPARTMENTS OF THE ARMY AND AIR FORCE

USPFO FOR MINNESOTA

PROCUREMENT DIVISION

15000 HWY 115, CAMP RIPLEY

LITTLE FALLS MN 56345-4173

W912LM 7. ADMINISTERED BY (If other than item 6)

4. REQUISITION/PURCHASE REQ. NO.

CODE

See Item 6

FACILITY CODECODE

EMAIL:TEL:

W912LM-11-R-0003

SECTION SF 30 BLOCK 14 CONTINUATION PAGE

SUMMARY OF CHANGES

SECTION SF 1449 - CONTINUATION SHEET

SOLICITATION/CONTRACT FORM

The required response date/time has changed from 22-Sep-2011 10:00 AM to 28-Sep-2011 10:00 AM.

SUPPLIES OR SERVICES AND PRICES

CLIN 0001

The CLIN description has changed from Per Event Charge to DELETE.

The CLIN extended description has changed from Contractor shall provide all equipment and supervision necessary to complete services as outlined in the Performance Work Statement. The Per Event Charge should include all costs not individually priced in CLINs 0002 through 0007. Base Year (Oct 1, 2011 - Sep 30, 2012) to

DELETE .

The pricing detail quantity has decreased by 12.00 from 12.00 to 0.00.

CLIN 0002

The CLIN extended description has changed from Dentist services with MN ARNG providing internal resources (i.e. staff, equipment, supplies) for exams.Base Year (Oct 1, 2011 - Sep 30, 2012) to Dentist services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep 30, 2012).

The pricing detail quantity has increased by 180.00 from 120.00 to 300.00.

CLIN 0003

The CLIN extended description has changed from Dental Technician services with Mn ARNG providing internal resources (i.e. staff, equipment, supplies) for exams.Base Year (Oct 1, 2011 - Sep 30, 2012) to Dental

Technician services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep 30, 2012).

The pricing detail quantity has increased by 360.00 from 240.00 to 600.00.

CLIN 0004

The CLIN description has changed from Dental Exam to DELETE.

The pricing detail quantity has decreased by 450.00 from 450.00 to 0.00.

CLIN 0005

The CLIN description has changed from Bite Wing X-Ray - Single Film to DELETE.

The pricing detail quantity has decreased by 100.00 from 100.00 to 0.00.

CLIN 0006

The CLIN description has changed from Bite Wing X-Ray - Two Bite to DELETE.

CLIN 0007

The CLIN description has changed from Panorex X-Ray to DELETE.

The pricing detail quantity has decreased by 300.00 from 300.00 to 0.00.

CLIN 1001

The CLIN extended description has changed from Contractor shall provide all equipment and supervision necessary to complete services as outlined in the Performance Work Statement. The Per Event Charge should include all costs not individually priced in CLINs 1002 through 1007. Option Year One (Oct 1, 2012 - Sep 30, 2013) to DELETE .

CLIN 1002

resources (i.e. staff, equipment, supplies) for exams.Option Year One (Oct 1, 2012 - Sep 30, 2013) to Dentist services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep

30, 2012).

CLIN 1003

internal resources (i.e. staff, equipment, supplies) for exams.Option Year One (Oct 1, 2012 - Sep 30, 2013) to Dental

Technician services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep 30, 2012).

The pricing detail quantity has increased by 360.00 from 360.00 to 720.00.

CLIN 1004

CLIN 1005

CLIN 1006

CLIN 1007

CLIN 2001

The CLIN extended description has changed from Contractor shall provide all equipment and supervision necessary to complete services as outlined in the Performance Work Statement. The Per Event Charge should include all costs not individually priced in CLINs 2002 through 2007. Option Year Two (Oct 1, 2013 - Sep 30, 2014) to DELETE .

CLIN 2002

resources (i.e. staff, equipment, supplies) for exams.Option Year Two (Oct 1, 2013 - Sep 30, 2014) to Dentist services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep

CLIN 2003

internal resources (i.e. staff, equipment, supplies) for exams.Option Year Two (Oct 1, 2013 - Sep 30, 2014) to

Dental Technician services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year

(Oct 1, 2011 - Sep 30, 2012).

CLIN 2004

CLIN 2005

CLIN 2006

CLIN 2007

CLIN 3001

The CLIN extended description has changed from Contractor shall provide all equipment and supervision necessary to complete services as outlined in the Performance Work Statement. The Per Event Charge should include all costs not individually priced in CLINs 3002 through 3007. Option Year Three (Oct 1, 2014 - Sep 30, 2015) to DELETE .

CLIN 3002

resources (i.e. staff, equipment, supplies) for exams.Option Year Three (Oct 1, 2014 - Sep 30, 2015) to Dentist services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep

CLIN 3003

internal resources (i.e. staff, equipment, supplies) for exams.Option Year Three (Oct 1, 2014 - Sep 30, 2015) to

Dental Technician services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year

CLIN 3004

CLIN 3005

CLIN 3006

CLIN 3007

CLIN 4001

The CLIN extended description has changed from Contractor shall provide all equipment and supervision necessary to complete services as outlined in the Performance Work Statement. The Per Event Charge should include all costs not individually priced in CLINs 4002 through 4007. Option Year Four (Oct 1, 2015 - Sep 30, 2016) to DELETE .

CLIN 4002

resources (i.e. staff, equipment, supplies) for exams.Option Year Four (Oct 1, 2015 - Sep 30, 2016) to Dentist services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year (Oct 1, 2011 - Sep

CLIN 4003

internal resources (i.e. staff, equipment, supplies) for exams.Option Year Four (Oct 1, 2015 - Sep 30, 2016) to

Dental Technician services to assist MNARNG with Dental exams, X-rays, etc. as specified in the PWS.Base Year

CLIN 4004

CLIN 4005

CLIN 4006

CLIN 4007

DELIVERIES AND PERFORMANCE

The following Delivery Schedule item for CLIN 0001 has been changed from:

DELIVERY DATE QUANTITY SHIP TO ADDRESS UIC

POP 01-OCT-2011 TO

30-SEP-2012

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

FOB: Destination

W77925

To:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0002 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0003 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0004 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0005 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0006 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 0007 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1001 has been changed from:

POP 01-OCT-2012 TO

30-SEP-2013

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1002 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1003 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1004 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1005 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1006 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 1007 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2001 has been changed from:

POP 01-OCT-2013 TO

30-SEP-2014

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2002 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2003 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2004 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2005 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2006 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 2007 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3001 has been changed from:

POP 01-OCT-2014 TO

30-SEP-2015

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3002 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3003 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3004 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3005 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3006 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 3007 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4001 has been changed from:

POP 01-OCT-2015 TO

30-SEP-2016

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4002 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4003 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4004 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4005 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4006 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following Delivery Schedule item for CLIN 4007 has been changed from:

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

MEDICAL READINESS OFFICE

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

N/A JOINT FORCES (J1) - MANPOWER &

PERSONNEL

BRIGHAM FANNING

OFFICE OF THE STATE SURGEON

600 CEDAR STREET

ST PAUL MN 55101

651-268-8841

The following have been modified:

PERFORMANCE WORK STATEMENT

PERFORMANCE WORK STATEMENT

DENTAL SERVICES

MINNESOTA NATIONAL GUARD

1. BACKGROUND:

Individual Medial Readiness (IMR) and Medical Readiness Classification (MRC) are the basic principles of force-sustainment for Army National Guard (ARNG) forces. Dental health is vital for force health protection and failure to achieve a standard of level of dental health could preclude a soldier from deploying. Dental Readiness is a soldier and command responsibility.

This Performance Work Statement (PWS) covers the various components of IMR/FMR to include, but not limited to: Annual dental exams, digital bitewings radiographs, digital panoramic radiographs, identification (to 90+%) of all Class 3 soldiers on alert orders. Services are to be completed on site at the General E.A. Walsh Training Site, Camp Ripley, Little Falls, MN. This PWS identifies the purpose of the work to be performed by the contractor and provides a description of the work to be completed and any required outcomes. The contractor shall provide qualified personnel to complete these tasks. ALL equipment and supplies will be provided by the MNARNG.

DoD established a uniform dental classification in HA Policy 02-11, Policy on Standardization of Oral Health and Readiness Classifications. DoD policy requires dental screening examinations and remediation to be accomplished and documented on 90%+ of service members. Members of the MNARNG shall receive an annual dental screening examination to determine their dental classification. Dental treatment that may be required is essential to be identified at the Soldier Readiness Processing (SRP) site to ensure the highest Dental Deployable Rate for the Mobilizing Soldiers.

2. OBJECTIVES AND SCOPE:

The objective of this PWS is to award a single contract to assist the MNARNG in completing the requirements of IMR/MRC –Dental Readiness on all eligible (mobilizing or not) Service Members (SMs). Dental services shall be performed by licensed professionals. Contractor shall be held liable and is responsible to ensure and verify the appropriate level of Credentialing / Privileging (Licensure, Diploma, etc.) for all contract providers in support of any service event.

DENTAL

Clinical evaluation by a licensed dentist of the oral cavity using a visual, clinical exam supported by bitewings taken by dental technicians.

Personnel performing the dental screening examination have a moral and ethical obligation to inform the Soldier if they observe or are apprised of any sign or symptom for which the Soldier should obtain further evaluation or care.

Hardcopy medical documentation file and organization in accordance with AR 40-66 in the Soldier Treatment Record (STR).

3. REFERENCES (http://www.usapa.army.mil/)

AR 40-501 Standards of Medical Fitness

AR 40-35 Dental Readiness & Community Oral Health Protection

4. ACRONYMS

DA Department of the Army DoD Department of Defense DTR Dental Treatment Record HIPAA Health Insurance Portability and Accountability Act IMR Individual Medical Readiness MNARNG Minnesota Army National Guard NGB National Guard Bureau OSArS Office of the State Army Surgeon OSHA Occupational Safety and Health Administration SRP Soldier Readiness Processing STR Soldier Treatment Record DSS Deputy State Surgeon

5. SERVICES TASKS - GENERAL

The contractor shall provide all labor necessary to provide all listed services Events are currently scheduled to take place at Camp Ripley, Little Falls, MN. Alternate locations throughout the State may be necessary. The services provided shall ensure that soldiers dental health meets mandated readiness and deployability standards to ensure mission capability of the MNARNG. A minimum of 30 days prior to a scheduled event, the MNARNG will notify the contractor of the number of personnel required accomplish required tasks.

DENTAL TASKS:

Digital Bitewings, Digital Panoramic Radiographs & Dental Exams: The contractor shall perform required dental examinations to include digital bitewings and digital panoramic radiographs if clinically indicated in support of the annual dental screenings in accordance with the AR 40-501 and AR 40-35. The contractor shall ensure all soldiers have a current Panoramic Radiograph on file and if missing, the contractor shall perform new radiographs. Adherence to all OSHA requirements, State and Federal Regulations are mandatory.

Exam. A periodic oral evaluation shall assess the current state of oral health, risk for future dental disease as well as assessing general health factors that relate to the treatment of the patient. 6 exams per hour are necessary to ensure completion during time available.

The following measures are required for each periodic oral evaluation:

a. Caries risk assessment – Classify Soldiers as low, moderate or high risk for caries as outlined by the American Dental Association’s 1995 Special Supplement. This assessment will allow the Army Dental Care System (ADCS) to identify those at high risk for future disease.

b. Periodontal assessment – Periodontal Screening and Recording (PSR), a screening procedure endorsed by the American Dental Association and the American Academy of Periodontology, should be utilized to determine the need for periodontal treatment.

c. Tobacco risk assessment – Classify Soldiers as a smoker, user of smokeless tobacco or both.

d. Oral cancer screening – Perform a thorough oral cancer screening on all soldiers as part of annual examinations.

e. Digital radiographs should be taken only for clinical reasons according to FDA guidelines as determined by the patient’s dentist. Radiographs should be of diagnostic quality, properly identified and dated. A panograph is required to be present in dental record and that it is of adequate quality for diagnostic/identification purposes. There is no time requirement on updating panographic radiographs. However, the panographic radiograph will adequately represent the current oral condition of the Soldier. Digital radiographs shall be performed on all service members who do not have a Panograph on file in the DENCLASS system, regardless of when the hardcopy panograph is dated or at the discretion of the State Dental Officer.

6. CONTRACTOR PROVIDED EQUIPMENT AND PERSONNEL:

Contractors shall provide all licensed personnel to perform the Dental Readiness service requirements. All equipment and supplies will be provided by the MNARNG.

Dental Staffing:

Dentist

Dental Assistant/Technician

7. APPLICABLE DOCUMENTS

The contractor shall ensure that all appropriate DA or DD forms (in accordance with references) are utilized for each service supplied. The forms will be made available through the State Medical Command office. The contractor shall provide all documentation concerning dental treatment (to include recommendations) to the MNARNG Office of the Deputy State Surgeon or Designee.

8. PLACE OF PERFORMANCE

Services are required at General E.A. Walsh Training Center, 15000 Hwy 115, Camp Ripley, Little Falls, MN 56345-4173. Other armory sites across the State may be utilized as deemed necessary by the Deputy State Surgeon.

9. PERIOD OF PERFORMANCE

The overall period of performance for this contract is 12 months. The typical performance will be one event per month, consisting of 3 days (Friday-Sunday). However the performance is specific to each event and may vary.

10. OTHER CONDITIONS/ SECURITY

Safety: The contractor shall establish a safety and health program in accordance with the standards of the Federal Occupational Safety and Health Standard (OSHA), Health Information Portability and Accountability Act (HIPAA), the Privacy Act and the American Dental Association

(ADA).

Performance work statement is “UNCLASSIFIED” and under HIPAA guidelines. OSArS shall notify the Contractor if requirement exists for a secret classification and circumstances requiring secret classification for Readiness impact reporting.

Quality Control: The contractor shall create a quality assurance program that monitors all services being provided. The program must be approved by the MNARNG Deputy State Surgeon within 10 days of contract award.

Hours of Operation: Soldiers will be made available to the contractor during regular drill weekends and training periods between the normal hours of operations to be estimated at 10 hours a day. Usual hours are between 0700 and 1900 unless special arrangements are made.

Security Requirements: All contractor employees and affiliated personnel of the contractor are to possess identification that identifies them as such. All vehicles are subject to search without reason. The contractor shall comply with any and all installation security requirements.

Reporting: The contractor shall provide a final report for all services provided to include a by name, unit, and social security number roster of all soldiers receiving services. The report shall be approved and verified by the MNARNG liaison with the Office of the State Surgeon.

See Appendix A.

Invoice: Contractor shall invoice using Wide Area Work Flow (WAWF). A detailed listing of all services provided shall be attached to the invoice.

11. ACCEPTANCE PLAN:

All work performed, and data to be submitted under this task will be made available to be inspected for compliance with the PWS and accepted by the COR or authorized representative as specified herein.

12. APPENDICES:

A. Estimated Workload Data B. Dental Classification

APPENDIX A

ESTIMATED WORKLOAD DATA

The following data elements will be reported at the end of an event:

Date Location List of contract employees Total number of patients scheduled Total number of patients examined Total number of Soldiers by dental classification: 1, 2, 3 Total number of bitewing radiographs (sets of 4 per patient) taken Total number of panograph radiographs taken A by name listing of all Soldiers examined and the dental classification of the Soldier

APPENDIX B

Department of Defense

Oral Health and Readiness Classification System

The oral health status of uniformed personnel shall be classified as follows:

a. Class 1 (Oral Health): Patients with a current dental examination, who do not require dental treatment or reevaluation. Class 1 patients are worldwide deployable.

b. Class 2: Patients with a current dental examination, which require non-urgent dental treatment or reevaluation for oral conditions, which are unlikely to result in dental emergencies within 12 months. Class 2 patients are worldwide deployable. Patients in dental class 2 may exhibit the following:

(1) Treatment or follow-up indicated for dental caries or minor defective restorations that can be maintained by the patient.

(2) Interim restorations or prosthesis that can be maintained for a 12 month period. This includes teeth that have been restored with permanent restorative materials for which protective cuspal coverage is indicated.

(3) Edentulous areas requiring prostheses but not on an immediate basis.

(4) Periodotium that:

(a) requires oral prophylaxis

(b) requires maintenance therapy

(c) requires treatment for slight to moderate periodontitis and stable cases of more advanced periodontitis

(5) Unerupted partially erupted or malposed teeth that are without historical, clinical or radiographic signs or symptoms of pathosis, but which are recommended for prophylactic removal.

(6) Active orthodontic treatment. The provider should consider placing the patient in passive appliances for deployment up to six months. For longer periods of deployment, the provider should consider removing active appliances and placing the patient in passive retention.

(7) Temporomandibular disorder patients in remission. The provider anticipates the patient can perform duties while deployed without ongoing care and any medications or appliances required for maintenance will not interfere with duties.

c. Class 3: Patients who require urgent or emergent dental treatment. Class 3 patients normally are not considered to be worldwide deployable.

(1) Treatment or follow-up indicated for dental caries, symptomatic tooth fracture or defective restorations that cannot be maintained by the patient.

(2) Interim restorations or prostheses that cannot be maintained for a 12 month period.

(3) Patients requiring treatment for the following periodontal conditions that may result in dental emergencies within the next 12 months.

(a) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(b) Active progressive moderate or advanced periodontitis.

(c) Periodontontal abscess

(d) Progressive mucogingival condition

(e) Periodontal manifestations of systemic disease or hormonal disturbances

(f) Heavy subgingival calculus

(4) Edentulous areas or teeth requiring immediate prosthodontic treatment for adequate mastication or communication or acceptable esthetics.

(5) Unerupted, partially erupted or malposed teeth with historical, clinical or radiographic signs or symptoms of pathosis that are recommended for removal.

(6) Chronic oral infections or other pathologic lesions including:

(a) Pulpal, periapical or resorptive pathology requiring treatment.

(b) Lesions requiring biopsy or awaiting biopsy report.

(7) Emergency situations requiring therapy to relieve pain, treat trauma, treat acute oral infections or provide timely follow-up care (e.g., drain or suture removal) until resolved.

(8) Acute Temporomandibular disorders requiring active treatment that may interfere with duties.

d. Class 4. Patients who require periodic dental examinations or patients with unknown dental classifications. Class 4 patients normally are not considered to be worldwide deployable.

QUALITY ASSURANCE

Service Delivery Summary Worksheet Dental Services

Objective: Provide on-site dental exams for the Minnesota National Guard at Soldier Readiness Process (SRP) events.

Services to be provided at the General E.A. Walsh Training Center, 15000 Hwy 115, Camp Ripley, Little Falls, MN with other locations as deemed necessary. Services will be performed on weekends (one weekend per month).

Deliverable

Performance

Standard

Acceptable Quality Level (AQL)

Method Used /

Frequency

Contractor provides qualified and sufficient personnel to conduct all required Dental

Services

Go/No Go Vendor coordinates with the Deputy State

Surgeon prior to conducting services to determine the personnel required to conduct dental services for in the period identified.

Contractor personnel to posses appropriate level of credentialing Review

Spot Check or

Inspection

Customer

Complaint

Contractor performs Dental

Exams at a rate of 6 per hour Go/No Go Contractor completes exams at a rate that will complete services within the identified period

Contractor completes Dental

Exams Completes

98% of all identified testing

Contractor completes oral exams IAW AR

40-501 & AR 40-35 & completes -

Caries risk assessment

Periodontal assessment

Oral cancer screening

Panoramic Radiographs as needed to represent soldiers current condition

Contractor completes required paperwork & final reporting Completes

98% of needed paperwork

Contractor completes any required paperwork for dental files – ie SF 603 & DA 5570 NLT 10 days.

Contract completes and submits final data to

Deputy State Surgeon & tracks special cases

Government Quality Assurance Plan:

In your role as Contracting Officers Representative (COR), you assume some Quality Assurance duties. You will monitor contractor performance, complete and sign the Quality Assurance Worksheet provided below at least monthly, but you can submit the worksheet more frequently if needed. This worksheet allows you to document compliance with the Contract and fill a regulatory requirement to ensure adequate oversight is being performed.

Quality Assurance Plan Worksheets are to be sent directly to the Contracting Officer (CO), not later than the 5 th day of the month following the service (every month). At a minimum, the COR must send a completed copy of the worksheet to the CO after the first month of service and for any months where there is a rating other than Green.

The CO will assume a quality performance rating of “Green” on all measured deliverables unless otherwise notified.

The quality rating may change from “Green” to “Red” without notice, however we encourage the COR to utilize the

“Yellow” quality rating to alert the CO of quality issues that have the potential for a “Red” quality rating if corrective action is not taken.

Any time the rating is less than Green the COR shall clearly document the worksheet to indicate what did or did not occur per the PWS requirement. When an observation indicates other than a “Green” rating, the COR will require the Contractor to initial the observation. Initialing the observation does not constitute concurrence with the observation; it only acknowledges that they have been made aware of the defective performance. If the Contractor’s response to an identified quality deficiency is unsatisfactory, the Contracting Officer will contact the Contractor to implement a plan of action to remedy the identified deficiency.

The COR referred to in this QAP is: MSG Brigham Fanning, 651.268.8841,Brigham.fanning@us.army.mil

Rating Description

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

Yellow

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

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

Red

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

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

RECEIVERS - DENTAL QUALITY ASSURANCE PLAN WORKSHEET

Performance Rating

Deliverable/Service

Quality

Rating

Causative Factors Effect on Mission Action Required / Date

Contractor provides Green Comments Unnecessary for “Green” QA Rating.

mailto:Brigham.fanning@us.army.mil qualified and sufficient personnel to conduct all required Dental Services

Yellow

Red

Contractor performs services 6 soldiers per hr Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes

Dental Exams Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Contractor completes required paperwork & final reporting

Green Comments Unnecessary for “Green” QA Rating.

Yellow

Red

Signed ____________________________________________ Dated ______________________________

QUANTITY INFORMATION

NOTE: ALL quantities provided are ESTIMATES for the contract period (one year). To determine monthly estimate, divide the total estimate provided by 12. Contractor is not quaranteed to perform the estimated number of hours listed.

(End of Summary of Changes)