W912PQ-17-Q-0003.pdf

SEE ADDENDUM

(No Collect Calls)

W912PQ-17-Q-0003 16-Dec-2016

b. TELEPHONE NUMBER

518-786-4747

8. OFFER DUE DATE/LOCAL TIME

12:00 PM 17 Jan 2017

5. SOLICITATION NUMBER 6. SOLICITATION ISSUE DATE

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

STANDARD FORM 1449 (REV. 2/2012)

Prescribed by GSA – FAR (48 CFR) 53.212

(TYPE OR PRINT)

(SIGNATURE OF CONTRACTING OFFICER)

ADDENDA X ARE

26. TOTAL AWARD AMOUNT (For Gov t. Use Only )

23.

CODE 10. THIS ACQUISITION IS

SUCH ADDRESS IN OFFER

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT

BELOW IS CHECKED

TELEPHONE NO.

W912PQ9. ISSUED BY

18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a. UNLESS BLOCK

7. FOR SOLICITATION

INFORMATION CALL:

a. NAME

CHRISTINE CAMPBELL

2. CONTRACT NO. 3. AWARD/EFFECTIVE DATE 4. ORDER NUMBER

(TYPE OR PRINT)

30b. NAME AND TITLE OF SIGNER 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a.UNITED STATES OF AMERICA

1 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1. 52.212-4. FAR 52.212-3. 52.212-5 ARE ATTACHED.X

25. ACCOUNTING AND APPROPRIATION DATA

1. REQUISITION NUMBER

20.

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED.

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, AND 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

0010949862

ARE NOT ATTACHED

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA ARE ARE NOT ATTACHED

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

SET FORTH HEREIN, IS ACCEPTED AS TO ITEMS:

. YOUR OFFER ON SOLICITATION

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN

% FOR:SET ASIDE:UNRESTRICTED ORX

SMALL BUSINESS

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

W912PQ - USP&FO-NY

ATTN: MNPF-PC

330 OLD NISKAYUNA ROAD

LATHAM NY 12110-3514

18a. PAYMENT WILL BE MADE BY CODE

RATED ORDER UNDER

DPAS (15 CFR 700)

13a. THIS CONTRACT IS A

13b. RATING

CODE15. DELIVER TO CODE W56PPG 16. ADMINISTERED BY

12. DISCOUNT TERMS11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

14. METHOD OF SOLICITATION

RFQ IFB RFPX

W56PPG - MEDCOM

SFC MICHAEL MITCHELL

1 BUFFINGTON STREET

BLDG 120

WATERVLIET NY 12189-4000

TEL: FAX:

(518) 786-4985FAX:

TEL: (518) 786-4740 SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$7,500,000

NAICS:

621210

X

OFFER DATED

29. AWARD OF CONTRACT: REF.

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

EMAIL:

TEL:

31c. DATE SIGNED

SEE SCHEDULE

SCHEDULE OF SUPPLIES/ SERVICESITEM NO. QUANTITY UNIT UNIT PRICE AMOUNT

24.22.21.19.

WOMEN-OWNED SMALL BUSINESS (WOSB)

ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

32g. E-MAIL OF AUTHORIZED GOVERNMENT REPRESENTATIVE

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

(CONTINUED)

PAGE 2 OF107

ACCEPTED, AND CONFORMS TO THE CONTRACT, EXCEPT AS NOTED: ______________________________________________________

32a. QUANTITY IN COLUMN 21 HAS BEEN

RECEIVED INSPECTED

32b. SIGNATURE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32c. DATE 32d. PRINTED NAME AND TITLE OF AUTHORIZED GOVERNMENT

REPRESENTATIVE

32e. MAILING ADDRESS OF AUTHORIZED GOVERNMENT REPRESENTATIVE 32f . TELEPHONE NUMBER OF AUTHORIZED GOVERNMENT REPRESENTATIVE

37. CHECK NUMBER

FINALPARTIALCOMPLETE

36. PAYMENT35. AMOUNT VERIFIED

CORRECT FOR

34. VOUCHER NUMBER

FINAL

33. SHIP NUMBER

PARTIAL

38. S/R ACCOUNT NUMBER 39. S/R VOUCHER NUMBER 40. PAID BY

41a. I CERTIFY THIS ACCOUNT IS CORRECT AND PROPER FOR PAYMENT

41b. SIGNATURE AND TITLE OF CERTIFYING OFFICER 41c. DATE

42a. RECEIVED BY (Print)

42b. RECEIVED AT (Location)

42c. DATE REC'D (YY/MM/DD) 42d. TOTAL CONTAINERS

STANDARD FORM 1449 (REV. 2/2012) BACK

Prescribed by GSA – FAR (48 CFR) 53.212

AUTHORIZED FOR LOCAL REPRODUCTION

PREVIOUS EDITION IS NOT USABLE

SEE SCHEDULE

20.

SCHEDULE OF SUPPLIES/ SERVICES

21.

QUANTITY UNIT

22. 23.

UNIT PRICE

24.

AMOUNT

19.

ITEM NO.

W912PQ-17-Q-0003

Section SF 30 - BLOCK 14 CONTINUATION PAGE

BILLING INSTRUCTIONS

BILLING INSTRUCTIONS

This Purchase is exempt from all Federal, State and Local Sales Taxes.

TAX IDENTIFICATION NUMBER 11-6002464

BILLING INSTRUCTIONS-IMPORTANT PLEASE READ

In order to be paid in a timely manner, please assist us by following the instructions listed below:

1. Establish this account for the New York Army National Guard:

US Property and Fiscal Office - New York

ATTN: MNPF-VP

330 Old Niskayuna Road Latham, New York 12110-3514

2. Please verify:

a. The vendor’s name & address (BLOCK 17A) specified on the Standard Form 1449, SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS (SF 1449), must match those on the invoice.

BLOCK 9 on DD1155, BLOCK 15A on SF 30.

b. Total cost billed cannot exceed the dollar amount on the SF 1449, DD1155, or SF 30. Do not exceed the amounts shown on the purchase order/contract without prior approval of the Contracting Officer. If you exceed your dollar amounts without the Contracting Officer’s approval you will not get paid your additional money. ONLY

CONTRACTING PERSONNEL HAVE THE AUTHORITY TO CHANGE OR MODIFY THIS

PURCHASE/DELIVERY ORDER. UNIT PERSONNEL DO NOT HAVE THE AUTHORITY TO CHANGE

THIS PURCHASE/DELIVERY ORDER. THERE ARE NO EXCEPTIONS.

3. A separate invoice is required for each SF 1449, DD1155, or SF 30 (cannot accept statements):

a. Electronically submit invoices via Wide Area Work Flow (WAWF).

b. Invoices should not be submitted until after the time period specified on the SF 1449, DD1155, or SF 30

c. Each invoice must reflect the DODACC (HQ0670).

d. Each invoice MUST have a vendor invoice number.

4. Any CONTRACTING QUESTIONS concerning this purchase/delivery order should be directed to the Purchasing Office (518) 786-4747, ATTN: Christine Campbell, (518) 786-4986, ATTN: Mark Walsh, (518) 786-4461, ATTN:

LarryMerwin, or (518) 786-4740, , , ATTN: Rick Powell (518) 786-0399.

CHANGES TO THIS PURCHASE ORDER

THE ABOVE LISTED CONTRACTING PERSONNEL ARE THE ONLY PERSONS

AUTHORIZED TO CHANGE OR MODIFY THIS PURCHASE/DELIVERY ORDER.

NO OTHER UNIT INDIVIDUAL HAS THE AUTHORITY TO CHANGE THIS

PURCHASE/DELIVERY ORDER. REPEAT, NO OTHER INDIVIDUAL BUT THE

CONTRACTING PERSONNEL LISTED IN THIS PARAGRAPH HAVE THE

AUTHORITY TO CHANGE THIS PURCHASE/DELIVERY ORDER. THERE ARE NO

EXCEPTIONS.

6. Inquiries on PAYMENTshould be directed to the Voucher Processing Office (518) 786-6045, Brent Betit, (518) 786-4719, Ms. Donna Mare . Mr. Robert June is the Vendor Pay Supervisor (518) 786-4368. You must have your contract number or purchase order number for assistance. The Financial Manger is COL Dennis Deeley

(518) 786-4687.

ALL VENDORS NEED TO BE REGISTERED AND ACTIVE IN SYSTEM for AWARD MANAGEMENT (SAM) (www.sam.gov) SO ELECTRONIC PAYMENT (EFT) IS

ROUTED CORRECTLY.

7. ELECTRONIC INVOICING (WIDE AREA WORKFLOW-WAWF) HAS BEEN IMPLEMENTED IN THE

ARMY NATIONAL GUARD. VENDORS ARE ENCOURAGED TO view AT THE WAWF WEB SITE TO BETTER UNDERSTAND THE SYSTEM http://www.wawftraining.com. .

Additional Wide Area Workflow (WAWF) Information:

WAWF Production site: https://wawf.eb.mil

WAWF Help: http://www.dfas.mil/ecommerce/wawf/info Invoice Pay Information: https://myinvoice.csd.disa.mil/indexContract Information:

http://eda.ogden.disa.mil/usersguide/contact/hlp001

8. All vendors have to be currently registered in System Award Management, http://www.sam.gov.

9. DELIVERY and TECHNICAL questions should be directed to: COL Michael Hannon

Section SF 1449 - CONTINUATION SHEET

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001 1 Job Mobile Dental Services

FFP

Provide mobile dental services for the NYANG in accordance with the attached Performance Work Statement (PWS) Wage Determination 2015-4144 Revision 2 Dated 12/29/2015 applies and is attached.

Technical Point of contact is COL Michael Hannon, CELL: 518-241-3969

FAX: 518-270-1523

michael.p.hannon.mil@mail.mil

Contractor Officer Represenatative (COR) is COL Michael Hannon

Estimated 52 days of mobile dental services required.

The pricing will be a firm fixed price "per day" with an estimate of 52 days each year. The number of days required for this service is an estimate ONLY and unused days in each calendar year will not be paid and will be de-obligated from the contract at the end of each period of performance or 1 year from date of award of contract

FOB: Destination

PURCHASE REQUEST NUMBER: 0010949862

NET AMT

0002 1 Job

CONTRACTOR MANPOWER REPORTING

FFP

Contractor Manpower Reporting Please note the Contractor Manpower Reporting requirement is mandated by the Dept. of Army and requires the reporting of the dollar value of labor hours for the performance of an awarded service.

For more information Statement of Work/Contractor Manpower Reporting paragraph 14.

Requiring Activity UIC W8BNAA is provided to facilitate reporting.

Contractor Manpower Reporting website: https://cmra.army.mil

PURCHASE REQUEST NUMBER: 0010949862

0003 1 Job OPTION Mobile Dental Services

FFP

Provide mobile dental services for the NYANG in accordance with the attached Performance Work Statement (PWS) Wage Determination 2015-4144 Revision 2 Dated 12/29/2015 applies and is attached.

Technical Point of contact is COL Michael Hannon, CELL: 518-241-3969

FAX: 518-270-1523

michael.p.hannon.mil@mail.mil

Contractor Officer Represenatative (COR) is COL Michael Hannon

Estimated 52 days of mobile dental services required.

The pricing will be a firm fixed price "per day" with an estimate of 52 days each year. The number of days required for this service is an estimate ONLY and unused days in each calendar year will not be paid and will be de-obligated from the contract at the end of each period of performance or 1 year from date of award of contract

0004 1 Job

OPTION CONTRACTOR MANPOWER REPORTING

FFP

Contractor Manpower Reporting Please note the Contractor Manpower Reporting requirement is mandated by the Dept. of Army and requires the reporting of the dollar value of labor hours for the performance of an awarded service.

For more information Statement of Work/Contractor Manpower Reporting paragraph 14.

Requiring Activity UIC W8BNAA is provided to facilitate reporting.

Contractor Manpower Reporting website: https://cmra.army.mil

0005 1 Job OPTION Mobile Dental Services

FFP

Provide mobile dental services for the NYANG in accordance with the attached Performance Work Statement (PWS) Wage Determination 2015-4144 Revision 2 Dated 12/29/2015 applies and is attached.

Technical Point of contact is COL Michael Hannon, CELL: 518-241-3969

FAX: 518-270-1523

michael.p.hannon.mil@mail.mil

Contractor Officer Represenatative (COR) is COL Michael Hannon

Estimated 52 days of mobile dental services required.

The pricing will be a firm fixed price "per day" with an estimate of 52 days each year. The number of days required for this service is an estimate ONLY and unused days in each calendar year will not be paid and will be de-obligated from the contract at the end of each period of performance or 1 year from date of award of contract

0006 1 Job

OPTION CONTRACTOR MANPOWER REPORTING

FFP

Contractor Manpower Reporting Please note the Contractor Manpower Reporting requirement is mandated by the Dept. of Army and requires the reporting of the dollar value of labor hours for the performance of an awarded service.

For more information Statement of Work/Contractor Manpower Reporting paragraph 14.

Requiring Activity UIC W8BNAA is provided to facilitate reporting.

Contractor Manpower Reporting website: https://cmra.army.mil

PERFORMANCE WORK STATEMENT

Performance Work Statement as of 1 Nov 2016

Performance Work Statement (PWS) 1Jan 2017 to 31 Dec 2019

For Dental Readiness In Support of:

Individual Medical Readiness (IMR) to include Dental exams, Treatment & Dental Class (DENCLASS) Entry for

Alerted and Non-Alerted Soldiers in the New York Army National Guard.

(NYARNG)

Event: MRW, SRP 2 and 3

This is a multiple event solicitation:

See Appendix E for Dates and Locations of Events.

Task Monitors:

Operations OIC, MEDCOM, NYARNG

(518) 270-1514 / Cell: 518-817-0918 lance.n.woodard.mil@mail.mil

1. DEFINITIONS/ACRONYMS:

ADA – Americans with Disabilities Act ASMR – ASM Research (MODS modules vendor) CAC – Common Access Card COR- Contracting Officer's Representative DA – Department of the Army DENCLASS – Dental Classification System, Electronic Dental Record System DD Form – Department of Defense Form DoD - Department of Defense DSS- Deputy State Surgeon FDA – Food and Drug Administration HA – Health Affairs HIPAA – Health Insurance Portability and Accountability ActIMR – Individual Medical Readiness LAN – Local Area Network MEDCOM-NY – Medical Command – New York MEDPROS – Medical Protection System MODS – Medical Operational Data System NG6H 2065 - Funding Classification for Dental Exams NYARNG – New York Army National Guard OCONUS – Outside Continental United States OSHA – Occupational Safety and Health Administration POC – Point of Contact PPE – Personal Protective Equipment PSR – Periodontal Screening and Recording SDO- State Dental Officer SF – Standard Form SOW – Statement of Work SRP – Soldier Readiness Processing TMJ – Temporo-mandidbular Joint VFRE 2020 – Funding Classification for Dental Treatment

2. BACKGROUND:

Oral health is vital for force health protection. Failure to achieve a standard of oral health could preclude a Soldier from deploying. Dental Readiness is a command responsibility. DoD established a uniform dental classification in HA Policy 02-11. DoD policy requires dental screening examinations to be accomplished and documented on 90% of service members. Members of the Army National Guard shall receive an annual dental screening examination to determine their dental classification. The results of that screening examination shall be entered into the DENCLASS database onsite live. The DENCLASS database updates the Army Medical Protection System (MEDPROS).

3. OBJECTIVES AND SCOPE:

The objective of this Statement of Work is to provide parameters and criteria for the conduct and completion of the Deployment requirements for Dental readiness including treatment for Soldiers of units listed above utilizing a mobile dental facility (either RV style, hauled trailer, temporary building, or within existing structures).

The Contractor shall comply with all New York State corporate and dental licensing requirements. The Contractor must provide documentation that it is authorized by the New York Secretary of State and New York State Education Department as an entity registered and licensed to provide dental services within New York State. The contractor shall provide all management, labor, material, equipment, certifications and supplies necessary to provide all listed services in compliance with HIPAA, Privacy Act, Radiologically-Compliant, OSHA, stand-alone environment. The services will meet mandated dental requirements and readiness and deployability standards to ensure mission capability of the NYARNG.

Development & planning, setup and breakdown of the Contractor’s equipment is the Contractor’s responsibility.

Automation, to include computers, printers, internet access, etc, shall be the sole responsibility of the contractor and shall be tested prior to the event. The pricing proposal should include all cost associated with each event.

All equipment and staffing shall be in place no later than 1/2 hour prior to scheduled start time of event.

Contractor shall have live event & Soldier tracking systems in place to report progress of events back to Point-of-Contact.

The requirements include:

� Clinical evaluation of the oral cavity by a New York licensed dentist employing visual clinical exam supported by digital bitewings. Digital Panographics must represent the Soldier’s current dental condition. Digital Panographs are to be taken if no panograph is found in the record and equipment and demonstrate proficiency in DENCLASS or if the Soldier has had major dental treatment since the last panograph. Two extractions, two root canals or four restorations shall be considered major dental treatment. Contract dentist may order an updated panograph if deemed clinically necessary to complete a proper dental exam. Radiographs will be taken by trained dental technicians. Such technicians shall be trained and demonstrate proficiency on the contractors x-ray equipment prior to taking x-rays on soldiers Panographs/bitewings must be digital images must have a printed photographic quality copy available in the dental health record and entered into DENCLASS by the contractor.

� Each exam will be entered into the DENCLASS reporting system in real time by ASM Research (ASMR) trained personnel and annotated on the SF 603 (Health Record – Dental) and the DA 5570 (Health Questionnaire for Dental Treatment) of the Soldier’s dental records, posted in the

Soldiers Dental Record per AR 40-66, and entered into the DENCLASS module of MODS.

Scanned copies of the DA 5570 into DENCLASS are not acceptable. The online DA 5570 available on DENCLASS must be completed for each Solider.

� A photo print of each digital bitewing radiograph (Radiograph) and (if necessary) digital panographic radiograph will be posted in the Soldiers Dental Record per AR 40-66, and entered into the DENCLASS module of the Medical Operational Data System (MODS).

� Personnel performing the dental examinations 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.

� A comprehensive dental examination identifies deficiencies. Dental treatments required to correct those deficiencies to deployment standards are authorized.

� When dentist is performing the examination and existing panoramic x-ray is on file he/ she must determine if significant changes have taken place where a new panoramic is required. ie.

multiple extractions or fillings.

4. GOVERNMENT- FURNISHED PROPERTY AND INFORMATION:

a. General. The Government will provide the following resources:

b. Facilities, Supplies, and Services. The Government shall provide operating space for

Occupational Safety and Health Administration (OSHA) compliant Mobile Dental Practices and an area to park mobile dental practice. All operations, except for administrative setup at Camp Smith Training Site, shall be located in the gravel area provided for mobile/RV trailers.

c. Information. The Government will provide the following:

1. The dates and number of days for an event with estimated PAX NLT fourteen days before any event. Daily PAX flow numbers will be provided seven days prior to the scheduled event.

2. State Dental Officer (SDO) or representative to answer questions, retrieve and approve dental treatment plans.

5. CONTRACTOR FURNISHED ITEMS:

Contractors may own or lease its fleet of Mobile Medical and Dental Services that meet all OSHA ADA & HIPAA standards to ensure a safe, comfortable and productive workspace for medical services under the Individual Medical / Dental Readiness Requirements. An acceptable fleet may include RV style, hauled trailer or temporary building. Contractor will provide all items and licensed personnel needed to complete the Dental Readiness requirements to include any employee benefits, Vacation days, Paid Holidays and Sick Leave plan.

The Mobile Dental Services must provide the following:

(1) Provide x-ray areas with a minimum of 3mm lead-lined barriers and leaded glass for any patient observation points for x-ray radiation protection or there must be a minimum protective buffer zone of 6 feet distance between the operator and the x-ray source.

(2) Perform digital bite-wing and panographic x-rays as needed for exam completeness and upload digital x-rays to DENCLASS.

(3) Provide available emergency medical resources consistent with OSHA standards, such as eye-wash station and distilled water tanks

(4) Have walled dental operatories to provide confidentiality for patients

(5) Provide temperature controlled rooms consistent with OSHA standard

(6) Have sterilization equipment in separate sterilization area

(7) Provide biohazard waste and sharps receptacles

(8) Provide fully functional electric powered professional quality dental chairs, compressor systems, vacuum systems and treatment instruments for fillings, extractions, root canals and other authorized treatment by NYARNG. If dental instruments or treatment kits are found to be inadequate or incomplete by NYARNG dental staff, replacement or additional equipment will be required with 4 hours of written notice from COR or representative to the project manager onsite.

(9) Provide fully functional office technology including LAN with redundant computer systems with printing/copying capabilities to include CD/DVD writer, and stand-alone copier with paper. Contractor provided LAN is required due to limited band width within the military resource.

(10) Adequate vehicle ventilation is required to minimize airborne pathogens.

(11) Photographic quality paper and photo printer is required for bite wing/panographic x-rays to provide enhanced image quality (1200 x 4800 dpi or better) for more accurate diagnostic exam.

(12) At dental check in station, have separate printer and computer dedicated to review Soldiers’ information found in DENCLASS, and the ability to print bite-wings and panographic x-rays onto photographic quality paper and place into Soldiers dental record.

Prior to an event, the contractor will print out, or store digitally for subsequent printout, the current diagnostic Panorex and bitewings less than 1 year old found in Denclass. Such printouts will be available to exam and treatment dentists and shall remain in the Soldiers hardcopy record post-mission. Such printouts shall be on photographic paper and have1200X4800 dpi printer quality consistent with section 5 paragraph 11.

(13) Staffing levels provided by the contractor must be adequate to complete the projected number of exams and treatments in the allotted time. If contracting staff is dismissed from the mission by the COR/SDO in the best interest of the Soldier, a replacement must be available no later than start time the follow day to maintain the same operational tempo.

(14) Staffing and equipment levels provided by the contractor must be adequate to complete the projected number of exams and treatments in the allotted time. Four bitewing radiographic and 2 panographic x-ray stations with adequate staffing are required with back up machines operational within two hours of machine failure.

(15) Contractor must disclose any teaming or sub-contracting arrangements. If a teaming or sub-contracting arrangement is contemplated, provide complete information as to the arrangement, including any relevant and recent past performance on previous teaming arrangements with same partner. If this is a first time joint effort, each party to the arrangement shall provide a list of past and present relevant contracts. By submission of its offer the offeror agrees it has obtained any necessary permissions or consent from subcontractors or teaming partners for the Government to discuss or disclose past performance information concerning subcontractors and teaming partners to the offeror during exchanges. Upon request, a copy of the consents or permissions shall be provided to the Contracting Officer. If the subcontractor does not agree to the prime discussing its information with the Government, those evaluation notices, if issued, will be passed through the prime in a sealed envelope from and to the sub and Government.

Contractor will also provide all applicable forms on hand: per DENCOM Regulation. These forms are available in MEDPROS/DENCLASS

(a) SF 603/603A,

(b) DA 5570 (signed) Health questionnaire envelope and DA5570 E form,

(c) DD 2005, (signed) Privacy Act Statement, HIPAA NOPP (Notice of Privacy Practices)

Acknowledgement label (signed)

Contractor must provide their own internet access as noted above.

Contractor is solely responsible for all electricity, i.e. generators.

Contractor is solely responsible for the disposal and control of all of the contractor’s general waste, infectious waste and sharps.

Contractor must use black ink only on all documentation.

Contractor must provide PPE (personal protective equipment) ie. safety glasses for all personnel and should be in scrubs or lab coat or disposable gown.

GENERAL INSURANCE, LICENSURE AND CERTIFICATIONS: The Contractor shall ensure all providers maintain at least minimum amounts of malpractice/liability insurance as required by state licensing requirements. The contractor is required to ensure that its subcontracts for provisions of health care services contain the requirements of the clause at 52.237-7, including the maintenance of medical liability insurance. The Contractor shall ensure that all providers, technicians and other health care professionals performing services under this agreement have current licenses, registrations, and/or certifications according to industry standard and as required for the specific state, commonwealth, district or territory in which they are providing contract services. The Contractor shall ensure that all HCPs have a current certification in basic life support, DEA registration and current infection control course.

6. SAFETY

The contractor’s safety program includes equipment training, occupational safety, health, and fire protection guidance to ensure the protection and health of all work personnel.

Contractor must comply with standard safety practices when refueling its vehicles/generators. External refueling safety procedures must be followed to include the use of drip pans, fuel absorbent pads and secondary containment of bulk fuel storage greater than 55 gallons. Should fuel spills occur the contractor will bear the cost of cleanup operations.

a. Radiation Safety

1. Have established written policies and procedures to assure compliance with applicable Federal, State, DOD, and Army radiation safety regulations and directives. These documents include staff emergency reaction plans, as necessary, and procedures for investigating and reporting radiation accidents or incidents, possible radiation overexposures to Soldier patients or contractor staff, and provisions to ensure the safe use of x-ray producing devices on humans.

2. Upon request by the COR/DSS/SDO, provide documentation regarding the Contractor's employee radiation safety training commensurate with potential radiation hazards with the x-ray producing devices they are using.

3. Upon request by the COR/DSS/SDO provide copies of Qualified Health Physics Expert's acceptance test and most recent health physics survey of each diagnostic x-ray machine. The acceptance test and the most recent survey include tests of electrical, mechanical, image quality and radiation (output) dose tests or measurements. This also includes verification of the adequacy of radiation protection shielding in and around the x-ray machine and x-ray facility (e.g., mobile van).

4. Certain radiation emitting products require the submission of product reports to FDA and the retention of records as included in 21 CFR Part 1002 .All manufacturers of electronic products are subject to the reporting of accidental radiation occurrences, as required by 21 CFR 1002.20.

http://www.fda.gov/cdrh/radhlth/xraystandard.html

Army AR 11-9, Army Radiation Safety Program, 28 May 1999.

http://www.army.mil/usapa/epubs/pdf/r11_9.pdf AR 40-5, Preventive Medicine, 22 July 2005.

http://www.army.mil/usapa/epubs/pdf/r40_5.pdf TB MED 52, Occupational and Environmental Health, Management and Control of Diagnostic, Therapeutic, and Medical Research X-Ray Systems and Facilities, 26 February 2002.

http://www.army.mil/usapa/med/DR_pubs/dr_a/pdf/tbmed521.pdf

Any Government-owned property must be protected during the period of time such property is under the control or possession of the contractor or contractor may be responsible for cost of replacement/repair.

7. STANDARD OPERATION:

a. Contractor will contact Safety Point of Contact (POC) at each location two weeks prior to event to coordinate placement of equipment and other requirements. Contractor will verify that equipment which is to be placed at a facility for a dental event will fit at that site and provide COR or designee a scaled sketch plan of trailer layout. For events to be held at Camp Smith Training Site a copy of the Camp Smith Safety SOP (standard operating procedure) shall be obtained at Range Control Headquarters, Building 501 and reviewed prior to commencing operations. For specific safety questions please contact the Camp Smith Safety Office at 914-788-7359. Contractor will coordinate placement of all vehicles 7 days prior to the event. Contractor will contact MEDCOM COR or designated representative who will assist in coordination.

b. Plan for the expected daily “pax” (soldier/patient) flow to be approx. 180-300per day. However, expect the number of Soldiers seen per day to vary. Not less than 14 days prior to an event, the contractor will be notified of number of work days, and start times. Within 7 days of a dental event contractor shall be notified of estimated daily PAX flow.

c. Dental Event dates and locations are not guaranteed and may be changed to benefit the NYARNG. The final dates and location shall be provided at least 14 days prior to each event. See appendix E for schedule of events. Updates to this schedule will be provided as they occur. Contractor shall perform projected dental examinations, to include digital bitewings with digital panographic x-ray as indicated. Dental Treatment is authorized and will be performed.

d. It is expected that 25 percent of Soldiers seen on a daily basis will be identified as dental class 3 and require dental treatment. Soldiers who require dental treatment for Medical Readiness events will normally receive up to 1.5 hours dental treatment unless Soldier is within 60-120 days of deployment in which case all class 3 dental treatment will be completed. Soldiers who require dental treatment at a, SRP2 or a Medical Readiness Weekend event (MRW)will receive up to 1.5 hours of dental treatment, additional treatment may be authorized if time allows and in consultation with SDO/ COR and contractor;

SRP 3 events3all DRC 3 treatment will be performed so Soldier is a DRC 1 or 2 prior to leaving the event.

Each day a list of Soldiers who cannot be classified as DRC 1 or 2 after treatment is completed at an SRP1/2 will be provided to the State Dental Officer, or his representative, with explanation of what treatment could not be completed and why.

e. Staffing and equipment levels provided by the contractor must be adequate to complete the projected number of exams and treatments in the allotted time. Four bitewing radiographic and 2 panographic x-ray stations with adequate staffing are required with back up machines available and put online within two hours of machine failure. The SDO/COR or designee may refuse the continued and future services at NYARNG missions of specific contract personnel (dentists , assistants, or staff)based upon evaluation of their clinical performance or any other metric he deems to be in the best interests of the Soldier. If staff is dismissed from the mission a replacement must be available no later than start time the follow day to maintain the same operational tempo. .

f. All of contractor’s equipment is subject to search when entering or exiting SRP/MRW sites.

Setup of contractor’s dental equipment is the sole responsibility of the contractor. The contractor will provide personnel at the setup and teardown site who are familiar with the site, to include location, and equipment setup placement. Breakdown of the contractor’s dental equipment is the sole responsibility of the contractor. Equipment placed on site by the Contractor will be removed within 48 hrs after the completion of each event, unless other arrangements are made with the facility and MEDCOM.

Prior to the commencement of each event the Contractor will contact MEDCOM POCs for event coordination.

Event OIC 518-270-1515 office Cell 518-469-5049 Operations OIC 518-272-4013 office Cell 518-817-0918 Operations NCOIC Cell 518-649-2282 Deputy State Surgeon 518-270-1510 office Cell 518-429-4102

8. SPECIFIC TASKS:

a. Setup of contractor’s dental equipment is to be completed either the day prior to event or day of the event provided they can be fully operational and able to take patients at least 1/2 hour prior to the start time of each event

b. The results of screening examination shall be entered into the DENCLASS database onsite live. Contractors will electronically enter all data into the DENCLASS database within 2 hours of operations the following day to include the upload of any radiographs taken during the event. No less than a 98 percent accuracy of all entries into DENCLASS must be met on a daily basis.

c. Contractor shall upload 603 treatment data within 24 hours of being informed that treatment plans have been reviewed by the SDO. This includes partial lists of treatment plans that may be expedited to accommodate the voucher authorization process.

d. Staffing

1. Seventy-two hours prior to a scheduled event contractor will provide to the COR and

SDO or designee, a by name and position staffing plan to support hours of operations, dental treatment, dental exams, and real time entry of DENCLASS for each Soldier, as described in section 3, based on the numbers provided for each mission.

2. At all events Contracted dentists should have strong general dentistry skills and possess a New York State Dental License. In addition one dentist shall be capable of performing molar root canal, and another capable of complex extractions, including impacted 3rd molar extractions. At least one dentist at the dental event location will be fully familiar with the terms and conditions of this Statement of Work.

3. Certified Dental Assistants must be licensed with the New York State Education

Department, Office of the Professions, to practice as a certified dental assistant in New York State.

Certifications shall be kept on hand by the contractor and produced if requested by the COR/SDO or designee. Those who are contracted to perform for x-rays must be familiar with and able to fully operate mobile dental equipment.

4. Dental exams and treatment provided by the contractor must be adequate to complete a minimum of 28 dental screening exams and eight treatment procedures per hour on average. At the accepted rate of 8 dental exams per dentist per hour, this would require three to four dentist for examinations and six dentists for treatment. The above is the minimum staff level allowed at an event, however based on workflow the contractor is expected to provide appropriate staffing to complete each day’s workload by 1800 hrs unless mission requirements change. This may include additional work hours after 1800 until mission is complete.

5. The Contractor will designate a separate responsible party for the coordination and handling of all Soldiers requiring treatment and exams, and a separate employed who is responsible for reviewing paperwork for accuracy, to include the 603 and 603a, prior to the SDO or his representative’s review. Each dentist must have a trained dental assistant/scribe to ensure proper recording and disinfection/sterilization of room/equipment between exams.

6. A separate responsible party shall be assigned to review all Denclass data entries and uploaded x-rays for accuracy and completeness prior to submission for review by the SDO or his representative.

e. On an as needed basis, the Contractor will either provide medication for pain control i.e.

NSAID or narcotic pain control and/or antibiotics as indicated or will provide payment for such medication having made prior arrangements with a local pharmacy. The Contractor is solely responsible for obtaining any medications. Contractor will keep a separate list of all medications issued to a Soldier after treatment is completed and provide a copy of this to the COR, or his designee, 24 hours after the event is completed. The list will include Soldiers name, SSN, medication provided and how many of each the Soldier received. Prescription documentation must follow New York State guidelines and must be in a child proof container.

f. Contractor must submit a plan for the follow up care of emergency dental complications as a result of treatment performed at any of these events. If Soldiers contact the contractor post mission requiring follow up emergency care, such contact will be reported to MEDCOM Dental Case Management within 48 hours of initial contact and continue to provide timely updates to Dental Case Management until issue is resolved. Contractor is solely responsible for the cost of this dental care. Based on past events approximately 10-12% of Soldiers who have received care at an event have required follow-up care.

Soldiers must have an option for care with 50 miles of home of record. This plan shall include a 24/7 toll free contact phone number to a case manager to provide triage, instructions and access to emergency care as indicated for suspected complications. Contractors are responsible for additional care up to 90 days after a Soldier receives treatment if the treatment performed on the Soldier fails or causes other problems. Examples may include further post-operative treatment complaints of pain in jaw or gums, filling issues, puss or exudates, dry socket, paresthesia or unusual swelling following extractions or restorations. This plan shall include the cost of any prescriptions required and a reimbursement method for the Soldier required to purchase a prescription. In no case shall it take more than 30 days to reimburse a Soldier/billing entity for prescriptions or other dental services provided once proof of payment or service is received by the Contractor.

9. QUALITY CONTROL

The contractor shall adopt a quality assurance program that monitors all service activities and ensures the highest quality customizable dental services available. It is the responsibility of the State Dental Officer to review and approve dental treatment plans before treatment is performed based on the guidelines provided by NGB.

a. EXAMS

The dental exam consists of digital bite wings, panograph, oral evaluation and completion of the SF 603A. The oral evaluation shall assess the current state of oral health, risk of future dental disease as well as assessing general health factors that relate to the treatment of the patient. All available dental records and uploads must be reviewed to determine if Soldier is up to date with NYARNG requirements. The following measures are required for each periodic oral evaluation:

1. Caries risk assessment – Classify Soldiers as low, moderate or high risk for caries, dental disease based on the current number of restorations or active carries present. This assessment will allow the State Dental Officer to identify those at high risk for future disease and appropriately manage their care.

2. 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. Only number 0,1,2,3,4 are acceptable and X must be used for missing sextant teeth.

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

4. Oral cancer screening – Perform a thorough oral cancer screening on all beneficiaries as part of all annual examinations. Exam is to include Lymph node exam of Head/Neck, lateral border and underside of tongue, palate, mucosa, cheeks and Thyroid.

5. Soldiers who are identified as being pregnant shall receive an exam only. DENCLASS will reflect the Soldier’s DRC based upon the exam. The 603 will note the Soldier is pregnant.

6. Radiographs should be taken only for clinical reasons according to FDA guidelines as determined by the patient’s dentist and as stated in Section 3, Objectives and Scope. Radiographs should be of diagnostic quality, properly identified and dated. A panograph is required to be present in both the dental record and in DENCLASS and should be of adequate quality for diagnostic/identification purposes. Requirement for updating panographic radiographs is only required if the Soldier has had major changes which include treatment or obvious worsening of dental condition or if not on record. The panographic radiograph should adequately represent the current oral condition of the Soldier.

7. Post operative x-rays to be performed on interproximal posterior restorations. Extra Oral Films to be taken on post operative extraction procedures.

8. Posterior restorations are to be amalgam unless composite is approved by the SDO or his representative.. Any composites used should be radiopaque..

9. Each exam will be entered into the DENCLASS reporting system in real time input by ASMR trained personnel within 2 hours of the start of the next day’s operations,(including digital x-rays). The DA 5570 must be signed by the dentist and the Soldier. The annotation on the SF 603 (Health Record – Dental) may be accomplished during the course of the event day. Accuracy of DENCLASS data entry must not be less than 98%. Information must be entered by personnel familiar with Dental terminology

10. As required, provide timely feedback and work progress/status as to the number of dental examinations completed to the Medical Team Officer in Charge, to include timelines and/or factors that may negatively impact processing 24 Soldier exams per hour.

11. Provide completion status to leader of the Medical Team Officer in Charge as to time requirements to complete jobs to ensure processing 24 Soldier exams per hour. Electronic entry of data into the DENCLASS database is required within 24 hours of completion of the Dental Screening mission to include the upload of any radiographs taken during the event.

12. Contractor shall be licensed on any services rendered and equipment operated during mission. Radiograph equipment should be licensed under the State of New York

13. Contractor must provide copies of the SF603 daily in alphabetical order to the State Dental Officer with Health history DA5570 stapled to the bottom.

14. Contractor must provide a copy of the treatment plans in alphabetical order to the State Dental Officer.)

10. APPLICABLE DOCUMENTS:

Contractor Must Provide proof of its authorization through the New York Secretary of State and New York State Education Department as an entity registered to provide dental services within the State of New York.

a. Contracted dental assistants must be licensed with the New York State Education Department Office of the Professions to practice as a Certified Dental Assistant in New York State Certifications will be produced upon the request of the State Dental Officer or representative or the COR.

b. Contractor’s Dentists must have current documentation of the following:

1. New York State Dental License

2. DEA (Drug Enforcement Agency) Registration, if applicable for dispensing medications

3. Proof of current Malpractice Insurance

4. BLS/CPR (Basic Life Support/Cardio Pulmonary Resuscitation) training certificate

5. New York State Infection Control Certificate of Training

6. Signed and dated examination protocol should be completed by each dentist. This should be sent to the State Dental Officer, LTC Arthur Bilenker, arthur.j.bilenker.mil@mail.mil, and MAJ Luis Garcia, luis.garcia9.mil@mail.mil, at least 48 hours prior to the mission. A hard copy must be furnished at the event prior to its commencement.

11. PLACES OF PERFORMANCE: (not a complete list)

South Street Armory 174 South Street, Auburn, NY 13021 Camp Smith Training Site Bldg 503, Cortlandt Manor, New York 10567 Niagara Falls Air Reserve Center 2502 Rubin Way, Niagara Falls, NY 14304 MATES Facility 4900 Tank Trail Rd, Fort Drum, NY 13602 Joint Forces Headquarters 330 Old Niskayuna Road, Latham, NY 12110 27th IBCT Headquarters 6900 Thompson Road, Syracuse, NY 13211 Hornell Armory

100 Seneca Street, Hornell, NY 14843

12. OTHER CONDITIONS/ SECURITY:

a. Safety: The contractor has established a safety and health program in accordance with the Federal Occupational Safety and Health Administration (OSHA) standard.

b. Performance work statement is “UNCLASSIFIED” and under HIPAA regulations. Contractor shall notify the contracting officer if requirement exists for secret classification and circumstances requiring secret classification for Readiness impact reporting.

c. Contractor’s affiliated dentists must be New York State Licensed to perform exams and treatment.

d. Contractor’s affiliated dentists performing examinations and treatment must have a chair-side Certified Dental Assistant for Soldier charting.

13. ACCEPTANCE PLAN:

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

14. CONTRACT MANPOWER REPORTING

Contractor Manpower Reporting (CMR): The contractor shall report ALL contractor labor hours (including subcontractor labor hours) required for performance of services provided under this contract for the ARMY collection site. The contractor is required to completely fill in all required data fields using the following web ad-dress: http://www.ecmra.mil/.

Reporting inputs will be for the labor executed during the period of performance during each Government fiscal year (FY), which runs October 1 through September 30. While inputs may be reported any time during the FY, all data shall be reported no later than October 31 of each calendar year. Contractors may direct questions to the help desk at http://www.ecmra.mil/.

Unit Identification Code (UIC) for the Requiring Activity: W8BNAA

Issuing Office DoDAAC: W912PQ

15. QUALITY CONTROL CHECK LIST:

1. SF 603A

a. Missing teeth marked with an “X”

b. Teeth to be extracted indicated with two parallel vertical lines

c. Impacted teeth enclosed within a circle

d. All class 3 restorations indicated on diagram of teeth and indicated in remarks section

e. Areas of teeth requiring restoration are colored in on diagram

f. All Dental Class 3 conditions are noted

g. All services provided are entered and dated. Include type and amount of anesthesia used

h. Soldier demographics are completely and accurately provided

i. TMJ evaluation entered

j. Blood Pressure recoded and entered

k. Soft Tissues examination: WNL: yes or no

l. Caries risk indicated

m. Tobacco use noted

n. Treatment/referral plan noted

o. Periodontal conditions/treatment note

p. All removable dentures whether they be full or partial, should be indicated at the time of examination and their status should be noted whether they are functional and present at the time of examination.

2. DA 5570 Health Questionnaire

a. Completed in full, including Soldier demographics

b. Positive answers explained

c. Medications noted

d. Tobacco use noted

e. Alcohol use noted

f. Latex Allergy documented: Yes or No

g. Dental radiographs in envelope

h. Electronically completed in DENCLASS

3. Digital Radiographs

a. Bitewings: No collimator cut, overlapping, angulation. Proper detail visible

b. Panographic radiograph: Proper head placement, no overlapping of cervical spine, no dog tags or chains.

c. Lead radiation protective aprons used

d. Panorex in Dental Record

4. OSHA Compliance

a. PPE for exams and treatment

b. Privacy screens

c. Six feet of space from radiography equipment

d. Sharps containers in place

e. Infectious waste disposal plan

f. Name tags for staff to include NAME & JOB TITLE i.e. Dentist/Tech.

5. The final dental classification will be determined by the State Dentist or his/ her representative.

16. APPENDICES.

A. Estimated Workload Data

B. Dental Classification

C. Authorized Dental Treatment

D. Pricing Sheets

E. Schedule of Events

F. Quality Assurance Plan and Worksheet

APPENDIX A

ESTIMATED WORKLOAD DATA

The following data elements will be provided in an excel spread sheet within 8 hours of end time each day for each day of the event. An event roll up will be provided 48 hours after the end of the event.

Date Location List of contract employees (providers, dental technicians and administrative staff)

DAILY REQUIREMENTS

For all Soldiers who received an exam the following information will be provided;

Time In, Patient Last Name, First Name, MI, SSN, Starting Dental Readiness Class, Dental Readiness Class after the exam, Pano taken, Bitewings taken, Exam given, check out time, Provider, and Remarks.

For all Soldiers who received dental treatment the following information will be provided;

Patient Last Name, First Name, MI, SSN, Starting Dental Readiness Class, Dental Readiness Class after treatment is complete, ADA Code Procedures, tooth number which received treatment , Provider, Tooth extracted and time out.

END OF EVENT REQUIREMENT

The roll up report will include all of the above information day by day, and the front page of this report will include the following information;

Total number of Soldiers examined, Total number of Soldiers by dental classification: 1, 2, 3, Total number of bitewing x-rays (sets of 4 per patient) taken, Total number of panograph x-rays taken, Total number of Soldiers in DRC 3 after the event, to include the ones not treated, Total number of Soldiers who did not receive treatment who are AGR/dental appointment pending, Total number of Soldiers eligible for treatment, Total number of Soldiers receiving treatment, Conversion rate from DRC 3 to DRC 1/2, and Verification of entry into DENCLASS.

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…