W912PQ24Q0038.pdf

SEE ADDENDUM

(No Collect Calls)

W912PQ24Q0038 05-Aug-2024

b. TELEPHONE NUMBER

518-786-4740

8. OFFER DUE DATE/LOCAL TIME

11:00 AM 13 Aug 2024

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 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

MELISSA SANTORO

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

0 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1. 52.212-4. FAR 52.212-3. 52.212-5 ARE ATTACHED.

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

0012149605

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 OR X

SMALL BUSINESSX

17a.CONTRACTOR/ CODE FACILITY

OFFEROR CODE

USPFO NY PURCHASING & CONTRACTING

330 OLD NISKAYUNA ROAD

LATHAM NY 12110-2224

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

W8BN NYARNG ELEMENT, JF HQ

W8BN NYARNG ELEMENT, JF HQ

330A OLD NISKAYUNA ROAD

LATHAM NY 12110-2299

TEL: 518-272-3700 FAX:

FAX:

TEL: SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

8(A)

HUBZONE SMALL

BUSINESS

SIZE STANDARD:

$41,500,000

NAICS:

621511

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 OF78

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.

W912PQ24Q0038

Section SF 30 - BLOCK 14 CONTINUATION PAGE

PWS

PERFORMANCE WORK STATEMENT OCCUPATIONAL HEALTH PROCUREMENT

OF MEDICAL SURVEILLANCE EXAMINATIONS:

1.0. General:

1.1. Scope: The medical examinations and procedures shall be the responsibility of the Medical Contractor. The administrative controls shall be the responsibility of the New York Army National Guard (NYARNG) Safety and Occupational Health Manager (SOHM). The Contractor’s medical provider (MD, PA, NP) and contractor will review the roster of employee exams and procedures, sign-off, date the exams and procedures, and return signed document within 2 business days of confirmation of contract, to establish written medical orders and contractors’ responsibility to fulfill the same. Any addition or removal of exams or procedures will be in consultation with the NYARNG Occupational Health Nurse (OHN) / Project Officer.

1.2. Background: The purpose of the NYARNG Mobile Occupational Medical Examination Program is to provide job-related medical surveillance examinations and occupational health services to NYARNG qualifying full-time support (FTS), part-time and temporary civilian technicians who are potentially exposed to health hazards in the work environment or who are assigned to positions requiring specific standards of physical fitness. The primary focus for FY24 will be: (1) evaluation of need for respirator in performance of duties, pulmonary function tests as needed, medical clearance, and respirator fit testing. Respirator fit testing and medical clearance will occur on approximately twenty-four (24) individuals. (2) Hearing testing, including otoscopic exams prior to testing, instruction to use of hearing PPE (plugs, muffs, caps, etc.) to include determining when to use protection, how to select the correct PPE, when double protection is to be used, donning / doffing, and maintenance of hearing protection. This may be provided in the form of a handout.

In addition to above, Medical Surveillance will include:

Vital Signs: Including height, weight, pulse, blood pressure.

Vision exams: Including distance, near, depth perception and field of vision. New employees will also receive color vision testing.

Laboratory tests: Including Urinalysis, Complete Blood Counts, Complete Blood Count w/ Differential, Comprehensive Metabolic Panels.

Updates to the medical surveillance roster will be provided to contractor at least 3 days before the start of the POP. The contractor shall conduct each for the quoted per test price provided in the quote and established in the contract. The government may evaluate the quality of professional and administrative services provided but retains no control over the medical professional aspects of services rendered. The contractor shall provide all labor, tools, supervision and supplies to conduct mobile medical surveillance / occupational health services for the NYARNG.

1.3. Period of Performance (PoP): The PoP shall be a total of thirty (30) days from 03 September – 03 October 2024. The specified exam days will be from 03 September – 13 September 2024 with standard hours of operation between 0700 and 1600. The contractor shall conduct medical surveillance examination / occupational health services at eight (8) work sites / locations as listed below:

DATE Host

Facility Location Attending

Facilities Number of Employees

Time

03 SEP 24 FMS 1 Buffalo FMS 1, 2, 10, FMS 2 Sub-shop

25 0800-1500

04 SEP 24 AASF 2 Rochester CSMS C, AASF

40 0730-1530

05 SEP 24 FMS 5 Syracuse FMS 4, 5, 6, 13 40 0730-1530 06 SEP 24 MATES Ft. Drum MATES and any individuals who missed MS or Require Follow-up

40 0730-1530

10 SEP 24 AASF 3 Latham FMS 3, 15, 16, 17, USP&FO, AASF 3, any individuals who missed MS or require Follow-up

30 0730-1530

11 SEP 24 CSMS A Camp Smith FMS 7, CSMS A

20 0730-1500

12 SEP 24 FMS 14 Farmingdale FMS 8, 9, 14, AASF 1

30 0730-1500

13 SEP 24 CSMS B Staten Island FMS 12, CSMS B

25 0730-1500

1.5. New York Army National Guard Project Officer: The NYARNG Project Officer is Christopher M. Gardner, OHN, MNAV-OS, 330 Old Niskayuna Rd, Latham, NY 12110- 2224. Commercial Phone (518) 786-6040, Fax (518) 786-6032, email:

Christopher.m.gardner43.civ@army.mil

2.0. References:

2.1. Department of Defense Instructions 6055.05-M, Occupational Medical Examinations and Surveillance Manual.

2.2. Army Regulation 40-5, Preventive Medicine.

2.3. Army Regulation 385-10, Army Safety and Occupational Health Program.

2.4. U. S. Department of Labor (DOL) 29 CFR 1910, Occupational Safety and Health Standards for General Industry.

2.5. Headquarters Department of the Army Pamphlet (DA PAM) 40-501, Hearing Conservation.

2.6. Military References made in the Performance Work Statement (PWS) are available from the government POC.

3.0. Procedures and Standards:

3.1. The contractor shall ensure that all procedures are conducted in accordance with applicable American Board of Occupational and Environmental Medicine (ABOEM), American Association of Occupational Health Nurses, U. S. Department of Labor, OSHA, and NIOSH Standards.

3.2. The contractor shall ensure that all clinical laboratory / chemistry services are performed by a laboratory licensed by the U. S. Department of Health and Human Services Health Care Financing Administration pursuant to the terms of the Clinical Laboratories Improvement Act of 1967 (42 U.S.C 263a) and the College of American Pathologists.

3.3. The contractor must supply a copy of all service provider certifications / licenses to the government with the contractor’s quote.

3.4. A comprehensive review and evaluation will be performed within thirty (30) days following the conclusion of testing. The NYARNG will contact and schedule a follow-up review and evaluation meeting to discuss overall performance of the purchase order.

3.5. The contractor will arrange for initial coordination of services with the government POC within fifteen (15) working days after award of the contract.

3.6. The contractor will arrange to consult with a representative of the NYARNG SOH or Contracting Office by telephone to coordinate or resolve issues that might arise before, during, and after the testing period. Any issues with testing must be reported immediately and no later than 30 minutes of findings so as not to delay the completion of testing. Any work that is not completed or is not completed within the time frame of the contract will be credited from the contract in an amount equal to the cost to have the matter addressed locally, if not fully resolved within two weeks of Medical Surveillance exam period.

3.7. Only qualified medical technicians will perform medical surveillance screening / testing elements. Personnel performing audiograms will be certified by the Council for Accreditation in Occupational Hearing Conservation (CAOHC).

3.8. Personnel conducting spirometry and fit testing will be certified through a program approved by the National Institute of Occupational Safety and Health (NIOSH). Copies of license and certifications must be provided to the Project Officer as previously indicated.

3.9. Instrumentation must meet or exceed appropriate performance standards, and accuracy must be verified IAW current Occupational Medicine Certification standards.

3.10. The contractor must provide the NYARNG Project Officer with a quality assurance medical surveillance plan, listing the procedures or processes which will be utilized to meet the performance work statement requirements.

3.11. The contractor shall safeguard all sensitive / Personally Identifiable Information and adhere to all HIPAA and NYARNG regulations regarding facility and personnel privacy and safety. The contractor shall provide documented confirmation that all contractor staff involved in administering any part of the contract have received annual HIPAA training.

3.12. While on NYARNG property, the contract employees shall display identification on their person indicating employing agency, name, and title. They shall make available, upon request, active government issued photo identification.

4.0. Medical Surveillance:

4.1.1. Physical examination, vital signs (including, pulse, blood pressure, height and weight), audiology testing for significant threshold shifts, including re-testing, vision (Including distance, near, color, depth perception, field of vision), respiratory clearance (including review of documentation, physical exam for fitness to wear respirator), pulmonary function test, medical clearance by qualified Board Certified Occupational Health and Medicine Provider, fit testing, respirator use, care and maintenance training, hearing protection training, with written report of all findings, recommendations and medical clearance, signed by provider. In lieu of a Board-Certified Occupational Health and Medicine Provider, a medically qualified and licensed provider with a minimum of five years military or occupational health experience may be substituted.

4.1.2. Should the medical provider find any employee is not medically cleared to perform the functions of their position, the Project Officer will be notified immediately by phone and in writing within twenty-four hours of findings. Notification will be in the form of a written medical referral form indicating follow-up clearance requirement that may remove any restriction to work. (Ex. Written referral. Follow-up vision exam and prescription glasses to correct near vision to better than 20:40 OU, based on employees work requirements).

4.1.3. It is the responsibility of the contractor to notify the Project Officer, within 30 minutes of completing what they deem to be the last employees, of any employees who were scheduled to attend medical surveillance but did not. The contractor may also notify the Project Officer, between 1100-1200, of any employees who had not yet attended. This will ensure Project Officer has time to reach out to supervisors to determine the status of the employee and assure greatest compliance. This notification is to occur while the contractor’s employees are at the facility to be able to provide contract services to all scheduled NYARNG Federal Civilian employees. The contractor or authorized employee will notify Project Officer if any employee who was not scheduled arrives for testing. The contractor understands there has been an estimated increase in number of employees built into this agreement to support employees returning from deployment or other details. The contract physician will add these employees to the master spreadsheet / orders and re-sign or initial (as appropriate) orders for those additional employees.

4.2. Laboratory testing: Will include the drawing of blood, collection of urine and disposal of all waste products generated by the blood draw and urine collection in accordance with the Blood-Borne Pathogen Standard. The waste products will not be disposed of at the testing site. The laboratory tests will consist of urinalysis (~95), CMP (~80), CBC (~5), CBC w/ Diff (~90). Tests may also include lead, ZZP, Hexavalent chromium, blood and urine cadmium, urine beta 2 microglobulin, Urine phenol, muconic acid, S-phenylmercapturic acid, BUN, creatinine, if determined necessary by contracting physician.

4.3. Respiratory clearance IAW OSHA Standard 29 CFR 1910.34 for identified employees. Contractor will utilize single-use, non-cross contaminating, disposable mouthpieces for pulmonary function tests (PFTs), to be able to perform PFTs regardless of environmental COVID or other environmental respiratory illnesses. Qualified contract staff shall fit test qualified employees who require or request voluntary use respirators in the workplace and provide education on the use, care, and maintenance of respirators, cartridges, and filters. This training may be in written format, and most be documented in the employees’ medical record. The employees will bring their respirators and filters / cartridges for fit testing.

4.4. Chest X-rays: Chest X-rays (CXR), 2 view / PA and Lateral or CXR w/ B Reader, will be completed on all aircraft mechanics, welders, surface maintenance mechanics and repairers, painters and allied trades technicians who have potentially been exposed to work site hazards, based on the most recent Industrial Hygiene survey or other identified risk, as determined by contract medical officer.

4.5. Audiogram:

4.5.1. Examiner: The following are the requirements for certified hearing technician examiners performing hearing testing for Army Hearing Conservation and Readiness.

4.5.2. Hearing testing must be completed by a physician, audiologist, or certified hearing technician.

4.5.3. Hearing technicians must administer audiometric tests under the supervision of a physician or audiologist.

4.5.3. Hearing technicians must have Council for Accreditation in Occupational Hearing Conservation (CAOHC) or equivalent military certification. Hearing technicians trained and certified at a military course will have the appropriate certification number assigned at the time of their course.

4.5.6. Hearing technicians certified at a civilian CAOHC course must obtain a DoD certification number that is compatible with the Defense Occupational Environmental Health Readiness System – Hearing Conservation (DOEHRS-HC) software from the U.

S. Army Public Health Command, Army Hearing Program. Requests for the DoD numbers should be submitted to usarmy.apg.medcom-phc.mbx.armyhearing-program@mail.mil by the installation Hearing Program Manager, Deputy State Surgeon, or Project Officer. The request should include a scanned copy of the CAOHC certificate and the hearing technician’s name, complete address, phone number and e-mail address.

4.5.7. Hearing Technicians will use the DOEHRS-HC program to administer hearing exams, if available. If not available, Hearing Technicians will print the hearing exam and have physician compare it to the most recent hearing baseline exam which will be provided to contractor by the Project Manager prior to the start of Medical Surveillance.

The physician will determine if a shift has occurred, and notification will be sent to the Project Manager within 24 hours of any employee requiring hearing follow-up. All hearing exams will be signed by employee, upon physician review and discussion with employee of findings, health education regarding protection of hearing and expectation of follow-up, if needed.

4.5.8. The contractor will have all data entered in DOEHRS through a certified individual who has access to DOEHRS-HC. This will be completed within five business days of hearing exam completion.

4.5.9. Hearing technicians shall be trained for otoscopic examination and earplug fitting and will perform otoscopic exams prior to audiology testing to identify and document any physical findings which may interfere with hearing exam (ex. Outer ear infection, obstruction by cerumen). Any employee who has findings which may interfere with a hearing exam will be referred to contract physician for assessment and documentation, prior to proceeding with the audiometry exam.

4.5.10. Contractor staff shall provide education to all NYARNG employees completing audiometric testing on prevention of hearing loss, proper donning, doffing, selection of plugs, muffs, caps and when to use single or double protection. This training may be in the form of written material. The education must be documented in the employee medical record.

5.0 Equipment:

5.1.1. Hearing testing will be completed using the approved DOEHRS-HC audiometer.

The current version of the DOEHRS-HC software must be utilized. IAW AR 40-501, Chapter 11g. (1) “The Defense Occupational Environmental Hearing Readiness Application – Hearing Conservation (DOEHRS-HC) audiometer is the only authorized audiometer for conducting and recording DD Form 2215 (Reference Audiogram) and DD Form 2216 (Hearing conservation Data).” The current DoD approved DOEHRS-HC audiometer is the Benson CCA 200 or CCA 200mini.

5.1.2. Audiometers must have an annual, comprehensive electro-acoustical calibration to ensure it is functioning properly and IAW the American National Standards Institute (ANSI) Standard S3.6. A copy of annual calibration will be provided to the Project Officer prior to the first day of Medical Surveillance.

5.1.3. Audiometers must pass a daily calibration and functional check. Daily calibration check results must be recorded on a DD Form 2217, Biological Audiometer Calibration Check.

5.1.4. Earphone cushions must be clean and in good condition, without dryness or cracks.

5.1.5. Headbands must be in good condition and provide proper tension.

5.1.6. Earphone cords must be in good condition with no cracks or breaks in the insulation or shorts in the wires.

5.1.7. Hearing booths must meet OSHA MPANL requirements with adequate insulation, adjustments in booths, and with booths in mobile units, with generators running.

Additionally, other tasks must not be taking place within the same room/space as hearing booth tests are occurring.

5.2. Test Environment:

5.2.1. Audiometric tests must be completed in a sound booth. The noise levels within the hearing test environment must not exceed those shown in DA PAM 40-501, Table 7-

1. Audiometric test booths must be evaluated on an annual basis and each time a mobile unit is moved, using sound level meter equipment conforming to:

5.2.2. At least the Type 1 requirements of the ANSI Standard S1.4-1983 (R 1997) and S1.4A- 1985 Amendment (or latest approved standard).

5.2.3. The band filter sets shall conform to requirements for Order 3, Type 3-D, extended range as specified by the latest ANSI Standard S1.11.

5.2.4. Sound booth noise measurements must be recorded on the U. S. Army Public Health Command Audiometric Test Booth Certification Form with a copy furnished to the Project Officer or their representative. Each new test, with move of mobile units, will be documented and emailed or faxed to Project Officer prior to hearing booth use. The USAPHC Audiometric Test Booth Certification Form is available at:

http://phc.amedd.army.mil/PHC%20Resource%20Library/AudiometricTestBoothCertific ation.pdf

5.2.5. Ventilation systems in audiometric test booths must provide adequate air exchange for patient comfort and acceptable sound levels for valid audiometric testing.

5.2.6. The standard for testing maximum permissible ambient noise levels (MPANL) within DoD is the ANSI S3.1, 1999 (R 2008) standard which requires sound measurements with a Type 1 sound level meter. The OSHA standard which allows measurements with a Type 2 sound level meter and allows much higher MPANL is not applicable for testing within DoD.

5.2.7. Hearing technicians will ensure that tests are completed in a sound booth that meets the DoD and Army Maximum Permissible Ambient Noise Levels (MPANL) IAW ANSI standards for MPANL and will ensure that the USAPHC Audiometric Test Booth Certification Form is posted on their test booth(s).

5.3. Audiometric Evaluation Requirements:

5.3.1. Hearing technicians will accurately enter their personal and certification information into the DOEHRS-HC system as examiners. Use of other examiners information is prohibited. Testing by a non-certified individual is prohibited. Incidents of falsified or shared examiner information shall be immediately reported to the USAPHC, Army Hearing Program, usarmy.apg.medcom-aphc.mbx.armyhearing-program@mail.mil

5.3.2. Hearing technicians will complete the daily functional checks and daily calibration on their DOEHRS-HC audiometers at the beginning of each test day with results recorded on a DD Form 2217, Biological Audiometer Calibration Check. The hearing technician will, upon request, provide the Hearing Program Manager, Case Manager, or their representative a daily copy of the DD Form 2217.

5.3.3. The hearing technician will ensure all Army National Guard Civilian employees have their Major Command identified as NGB in the DOEHRS-HC system and that the correct state or territory is selected for the Civilian employee being tested. Contractor hearing technicians will ensure that when they test on site for Army National Guard contracts their DOEHRS-HC examiner information lists the state or territory where they are testing.

5.3.4. The hearing technician shall ensure that all demographic information for personnel tested is entered correctly and accurately at the time of the test. This includes name, DOB, SSN, Gender, DoD Component (Army), Service Component (Federal Employee), Rank/Grade (GS or WG ONLY), SDOC (Occupation Code can be found in usajobs.gov or OPM.gov), UIC/WIC (FMS, AASF, MATES, and USP&FO), Branch/Career/Activity Code (Field Maintenance Shop, Army Aviation Support Facility, Maintenance Training and Equipment Site), Major Command (NGB), Location/Place of Work (Ex. Buffalo/AASF1), Test Type Annual (unless DOEHRS directs a follow-up 1 or 2 is required) or Reestablish if negative STS after Annual is completed. All other data as required.

5.3.5. Hearing technicians will not enter noise data unless there is specific noise exposure information available for the individual being tested.

5.3.6. Otoscopic examinations will be performed prior to all hearing test.

5.3.7. Hearing technicians will ensure hearing aids and any other objects that may interfere with testing (glasses, earrings, gum, etc.) are removed prior to administering any monitoring audiometry hearing tests.

5.3.8. DD Form 2215 and DD Form 2216 Audiograms will be completed using the DOEHRS-HC system. Thresholds will be completed for 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz and 6000 Hz using the Benson CCA 200 or CCA 200mini audiometer, Standard Test Configuration, Modified Hughson-Westlake threshold procedure, and DoD Significant Threshold Shift method.

5.3.9. The hearing technician shall use the appropriate form and ensure that all DD Form 2215 and DD Form 2216 audiograms are printed immediately following the completion of the test.

5.3.10. Hearing test results will be explained to the individuals being tested, and have employee sign the form at the conclusion of each test.

5.3.11. DOEHRS-HC automatically generates recommendations for referral when specific criteria are met. A copy of the referral, along with the DD2215 or DD2216, will be printed and sent to contract physician for review. The contract physician or representative shall inform both the individual and the Project Officer of the need for a referral at the time of the test. The employee shall sign the DD2215 or DD2216 at the time of notification of the need for follow-up. The referral will be given to employee, along with a written referral for re-test or audiology exam. A second copy will be sent to the Project Officer within 24 hours of identifying a referral is required. This will serve as proof of notification to Project Officer.

5.3.12. The hearing technician shall ensure that all consult referral forms are printed and saved immediately following the completion of the test.

5.3.13. In the event of a negative STS, hearing technicians will ensure that the follow-up test is repeated on the same day. If a negative STS is confirmed, a new baseline will be re-established by the Contractor at the time of testing.

5.3.14. In the event of a positive significant threshold shift (STS), hearing technicians will Repeat the test, after a 30-minute period of the employee not being exposed to noise. The Hearing Technician will use the better of the two tests. The Hearing Technician will ensure the individual signs the DD Form 2216 to acknowledge that the test results and, if necessary, required follow-up steps were explained to the individual.

5.3.15. In the event of a positive STS, the Project Officer or their representative will be notified at the time of the test but no later than 1630 on the day of testing so the follow-up hearing test(s) can be scheduled within thirty (30) days of the periodic test. Copies of all positive STS test results shall be sent to the Project Officer within 24 hours of testing.

Follow-up tests may be completed on a make-up Medical Surveillance Day by the contractor at the discretion of the Project Officer and at no additional cost to the Agency.

5.3.16. The Hearing Technician will ensure that employee’s positive STS follow-up tests are performed after being noise free for at least fourteen hours prior to the re-test.

5.3.17. All DOEHRS-HC data must be uploaded or entered into the DOEHRS-HC Data Repository by the contractor or their representative, no later than five business days after the employee is tested.

5.3.18. The hearing technician will, upon request, provide the Project Officer or their representative desired reports at the end of each test day. All daily audiometer calibration reports will be submitted to the Project Officer within thirty days of completion of Medical Surveillance exams.

6.0. Vital signs:

6.1. Vital signs will include height, weight, pulse, and blood pressure, if indicated on the spreadsheet, which will be provided to the contractor after all contract documents are secured, as well as periodically with updates.

7.0. Visual exams:

7.1. Visual exams will include, distance, near, color, depth perception, field of vision, if required. All abnormal findings will be discussed with employee at the time of finding and documented on a referral form which will be given to the employee at time of exam.

Project Officer will be notified in writing on a referral form within twenty-four hours of any abnormal findings by having contractor or representative send copy of the written referral to Project Officer. An additional copy will be included in the employee’s medical record sent to the employees’ home of record.

7.2. All abnormal findings not likely related to the employee’s job and requiring follow-up with a private health care provider will be communicated to the employee by way of a written referral at the time of identification of the abnormal finding with a copy of the same provided to the Project Officer and a third copy included in the employee’s medical record which is sent to the employees’ home of record.

8.0. Physician Services:

8.1. Physician will provide an on-site evaluation of the mobile testing to the (FTS) employees at the time of other testing as indicated in the Medical Surveillance Roster and as determined by the contract medical provider, in consultation with the Project Officer, based on employee potential exposure risks.

8.2. The Physician’s evaluations will be provided at the locations delineated in paragraph 1-4.

8.3. Physician will review all laboratory tests, x-rays and medical records and determine if the employee requires follow-up and / or is cleared for work duties. Any employee requiring follow-up will receive a written referral at time of evaluation or when laboratory results are received, indicating need for follow-up. A general statement can be made stating that the employee should bring their medical record to their private healthcare provider to assess identified abnormal findings that are not known to be work related but, may impact the employees’ health or ability to work in the future if not addressed. If the finding does not appear to be work related but does prevent the employ from preforming their duties, that must be stated and submitted to the Project Officer immediately, within 24 hours of identification. If the finding is work related, that also must be noted and the Project Officer must be notified immediately, within 24 hours as well.

9.0. Medical Records and Reports:

9.1. The contractor will ensure two (2) copies of the employee examination findings are furnished. One copy is to be sent to the NYARNG Project Officer, and one copy is to be mailed directly to the individual employee’s home of record. The medical examination records shall be sent to the employee’s home of record in a secured, confidential envelope. Medical examination results shall include all diagnostic tests, graphs, charts, reports, and examination results, written referral (This may be in the form of one document and include all required medical follow-up). The contractor will provide the NYARNG Project Officer with a hardcopy of these records within thirty (30) working days of the completion of testing. The contractor will also provide the Project Officer the medical examination records stored as individual files in alphabetical order on compact disc format capable of being uploaded into the Defense Occupational Environmental Health Readiness System (DOEHRS), within thirty (30) working days of completion of Medical Surveillance examinations and include test results. Results of Medical Surveillance testing which are questionable and / or of critical significance will be communicated directly, and immediately, to the NYARNG Project Officer by telephone and electronic or express mail. All abnormal findings which require follow-up are to be communicated to the Project Officer by sending a copy of the referral within 24 hours via secured email. If any employee is not medically cleared, the contractor must notify the Project Officer immediately by phone and forward the referral within 24 hours.

9.1.2. The Project Officer’s copy of employee medical records shall be placed in a manila folder with a straight cut tab on top. A 15/16 inch x 3 7/16 inch white folder label shall be affixed to the top, right, front side of the folder tab.

9.1.3. An identification label shall also be affixed to each page of the medical record which does not already include at minimum, employees full name (last, first, MI), as follows:

a. Affix to the bottom left margin of each page of the employee medical record, a 15/16 inch x 3 7/16 inch white label, in a manner that the label does not obscure and

b. Labels for the folder and the pages of the employee medical record shall include the following information in all caps, using Arial 10pt. font and printed as follows:

Line 1: Left margin, Employee’s full name (Last, First, Middle) as documented on the Medical Surveillance roster, then 5 spaces, then date of birth as follows: DOB: YY-

MM-DD

Line 2: Blank Line 3: Left margin. Social Security Number in format XXX-XX-XXXX

c. Should there not be adequate space on the first line to include the above information, place a dash (-) at the end of the first line and continue text on the second line. Then, leave the third line blank and place the SSN on the fourth line.

9.2. The Contractor will provide a comprehensive report that outlines the following in an Excel Spread Sheet Format:

a. Column # 1 – Personnel Name

b. Column # 2 – SSN

c. Column # 3 – D.O.B.

d. Column # 4 – Sex

e. Column # 5 – Facility of employment

f. Column # 6 – Position

g. Column # 7 – Wage Grade (WG or GS codes)

h. Column # 8 – Phys Exam (PE) and Medical Clearance (MC), (-/-): N = normal, A = abnormal, / C = cleared, O = not cleared,

i. Column # 9 – Vitals: Temp., Pulse, Blood Pressure (B/P), Resp. N = normal, A = abnormal,

j. Column # 10 – Audiology – N = anormal w/ no significant threshold shift, A = abnormal with significant threshold shift, O = Early Warning

k. Column # 11 – Vision with Corrective Lenses: N = normal, A = abnormal,

l. Column # 12 – Spirometry/PFT - N = normal, A = abnormal, X – Test Not Performed,

m. Column # 13 – Respirator use clearance P = Pass, F = Fail, X – Test Not Performed,

n. Column # 14 – Urinalysis – N = normal, A = abnormal, X – Test Not Performed,

o. Column # 15 – Comprehensive Metabolic Panel (CMP) - N = normal, A = abnormal, X

– Test Not Performed,

p. Column # 16 – Complete Blood Count (CBC) - N = normal, A = abnormal, X – Test Not Performed,

q. Column # 17 – CBC w/ Differential (CBC w Diff) – N = normal, A = abnormal, X – Test Not Performed,

r. Column # 18 – Lead (Pb) and Zinc Protoporphyrin (ZZP) – N = normal, A = abnormal, X – Test Not Performed,

s. Column # 19 – Hexavalent Chromium (CH6) - N = normal, A = abnormal, X – Test Not Performed,

t. Column # 20 – Blood Cadmium - N = normal, A = abnormal, X – Test Not Performed,

u. Column # 21 – Urine Cadmium - N = normal, A = abnormal, X – Test Not Performed,

v. Column # 22 – Urine Beta 2 Microglobulin (B2M) - N = normal, A = abnormal, X –

Test not performed,

w. Column # 23 – Blood Ureic Nitrogen (BUN) - N = normal, A = abnormal, X – Test not performed

x. Column # 24 – Creatinine (Creat) - N = normal, A = abnormal, X – Test not performed

y. Column #26 – CXR 2 View PA & Lat - N = normal, A = abnormal, X – Test not performed

z. Column #27 – CXR w/ B Reader - N = normal, A = abnormal, X – Test not performed

aa. Employee Medically Cleared - Y = Yes, N = No

ab. Notes: Written referral copy included – Y -Yes, N – Not applicable

10.0. Logistics:

10.1. Examination scheduling: Coordination of scheduling shall be a joint effort between the Project Officer and the Contractor, a draft copy of the scheduled will be initiated by the Program Office and sent to the Contractor for review and any needed adjustments.

One patient/employee per 12-minute intervals. All workdays include a one-hour lunch break. No testing shall be performed between 1130 – 1230 hours.

10.2. In the event of a Contractor equipment failure, specific testing and / or parts of examinations that are not completed during the testing period shall be completed at a scheduled time mutually convenient for the Contractor, Occupational Health Specialist, and the Facility(ies) but will be no later than two weeks from the last exam date listed in the Statement of Work. Unfinished testing / examinations will be completed at no additional cost to the Government. The option to schedule any component of Medical Surveillance exams not completed due to equipment failure or other contractor related events, through a local occupational medical facility, shall be done at no cost to the Government. The Contractor shall be directly responsible to cover costs for completing these make-up evaluations and the amount will be directly deducted from the final contract amount, without exception.

10.3. Medical surveillance testing shall be accomplished via a state-of-the-art mobile unit designed to be conducive to an efficient continuous flow of patients yet maintain the dignity of the patient and always achieve complete individual privacy. The unit should be designed to enhance maintenance of hygiene, e.g., running water sources should be distributed throughout the unit so that personnel movement is minimized, but that people undergoing examinations have access to hand washing and hygiene amenities.

Features of the unit should include, but are not limited to, a climate -controlled atmosphere, patient waiting/holding area for registration, separate changing room, separate on board restroom, testing/phlebotomy station, individual audiometric testing booth, on-board x-ray processing, an on-board computer system to maintain the quality control during the data entry and physician examination area. The unit should be physically structured such that each examination component can be conducted independently, e.g., with respect to the EKG and the examination conducted by the physician, an EKG and a physician's exam should be able to be conducted concurrently.

10.4. The Contractor shall provide a schematic and sufficient interior and exterior photographs of the unit proposed for use under the contract with their quotes, such that the Government can determine the Contractor has met the requirements set forth in this paragraph. Mobile units are to be equipped with separate power source / generator to operate in conditions without access to shore power.

11.0. Personal Protective Equipment (PPE):

11.1. Contractor shall furnish and assure health workers are provided with appropriate PPE such as, but not limited to, gloves, protective eyewear etc., where there is a potential for exposure to blood or other potential infectious materials.

11.2. Contractor will ensure each health care worker complies with the requirements of 29 CFR 1910.1030 Blood-borne Pathogens Standard

12.0. Infectious Waste Disposal:

12.1. Disposal of all infectious waste must be in accordance with local, state, and federal regulation and disposal of by the contractor.

12.2. Puncture resistant sharps containers must be readily accessible to health care workers and located in all treatment areas where sharps could potentially be used.

13.0. The contractor will comply with all New York State COVID-19 guidelines. If Medical Surveillance is delayed due to COVID-19 or other Federal or State emergency, the contractor and Project Officer will determine alternate dates for completion of Medical Surveillance.

Section SF 1449 - CONTINUATION SHEET

ITEM NO SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

0001 1 Job

FY 24 MEDICAL SURVEILLANCE

FFP

FY 24 MEDICAL SURVEILLANCE per the PWS (attached).

The Service Contract Act Wage rates apply and are incorporated.

FOB: Destination

PURCHASE REQUEST NUMBER: 0012149605

PSC CD: Q403

NET AMT

INSPECTION AND ACCEPTANCE TERMS

Supplies/services will be inspected/accepted at:

CLIN INSPECT AT INSPECT BY ACCEPT AT ACCEPT BY

0001 Destination Government Destination Government

DELIVERY INFORMATION

CLIN DELIVERY DATE QUANTITY SHIP TO ADDRESS DODAAC /

CAGE

0001 POP 03-SEP-2024 TO

13-SEP-2024

N/A W8BN NYARNG ELEMENT, JF HQ

W8BN NYARNG ELEMENT, JF HQ

330A OLD NISKAYUNA ROAD

LATHAM NY 12110-2299

518-272-3700 FOB: Destination

W56PPG

CLAUSES INCORPORATED BY REFERENCE

52.203-18 Prohibition on Contracting With Entities That Require Certain

Internal Confidentiality Agreements or Statements-- Representation

JAN 2017

52.203-19 Prohibition on Requiring Certain Internal Confidentiality Agreements or Statements

JAN 2017

52.204-7 System for Award Management OCT 2018 52.204-9 Personal Identity Verification of Contractor Personnel JAN 2011 52.204-10 Reporting Executive Compensation and First-Tier

Subcontract Awards

JUN 2020

52.204-13 System for Award Management Maintenance OCT 2018 52.204-16 Commercial and Government Entity Code Reporting AUG 2020 52.204-18 Commercial and Government Entity Code Maintenance AUG 2020 52.204-19 Incorporation by Reference of Representations and

Certifications.

DEC 2014

52.204-22 Alternative Line Item Proposal JAN 2017 52.204-23 Prohibition on Contracting for Hardware, Software, and

Services Developed or Provided by Kaspersky Lab Covered Entities

DEC 2023

52.204-25 Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment

NOV 2021

52.209-2 Prohibition on Contracting with Inverted Domestic Corporations--Representation

NOV 2015

52.209-6 Protecting the Government's Interest When Subcontracting With Contractors Debarred, Suspended, or Proposed for Debarment

NOV 2021

52.209-10 Prohibition on Contracting With Inverted Domestic Corporations

NOV 2015

52.212-1 Instructions to Offerors--Commercial Products and Commercial Services

SEP 2023

52.212-4 Contract Terms and Conditions--Commercial Products and Commercial Services

NOV 2023

52.212-5 (Dev) Contract Terms and Conditions Required to Implement Statutes or Executive Orders--Commercial Products and Commercial Services (Deviation 2023-O0008)

MAY 2024

52.219-6 Notice Of Total Small Business Set-Aside NOV 2020 52.219-28 Post-Award Small Business Program Rerepresentation FEB 2024 52.219-33 Nonmanufacturer Rule SEP 2021 52.222-3 Convict Labor JUN 2003 52.222-21 Prohibition Of Segregated Facilities APR 2015 52.222-26 Equal Opportunity SEP 2016 52.222-36 Equal Opportunity for Workers with Disabilities JUN 2020 52.222-50 Combating Trafficking in Persons NOV 2021 52.223-1 Biobased Product Certification MAY 2024 52.223-5 Pollution Prevention and Right-to-Know Information MAY 2024 52.225-3 Buy American--Free Trade Agreements--Israeli Trade Act NOV 2023 52.225-13 Restrictions on Certain Foreign Purchases FEB 2021 52.225-18 Place of Manufacture AUG 2018 52.225-20 Prohibition on Conducting Restricted Business Operations in

Sudan--Certification

AUG 2009

52.226-8 Encouraging Contractor Policies To Ban Text Messaging While Driving

MAY 2024

52.229-12 Tax on Certain Foreign Procurements FEB 2021

52.232-33 Payment by Electronic Funds Transfer--System for Award Management

OCT 2018

52.232-39 Unenforceability of Unauthorized Obligations JUN 2013 52.232-40 Providing Accelerated Payments to Small Business

Subcontractors

MAR 2023

52.233-3 Protest After Award AUG 1996 52.233-4 Applicable Law for Breach of Contract Claim OCT 2004 52.237-2 Protection Of Government Buildings, Equipment, And

Vegetation

APR 1984

52.247-34 F.O.B. Destination NOV 1991 52.253-1 Computer Generated Forms JAN 1991 252.203-7000 Requirements Relating to Compensation of Former DoD

Officials

SEP 2011

252.203-7002 Requirement to Inform Employees of Whistleblower Rights DEC 2022 252.203-7005 Representation Relating to Compensation of Former DoD

Officials

SEP 2022

252.204-7003 Control Of Government Personnel Work Product APR 1992 252.204-7012 (Dev) Safeguarding Covered Defense Information and Cyber

Incident Reporting (DEVIATION 2024-O0013 REVISION 1)

MAY 2024

252.204-7015 Notice of Authorized Disclosure of Information for Litigation Support

JAN 2023

252.204-7016 Covered Defense Telecommunications Equipment or Services -- Representation

DEC 2019

252.204-7017 Prohibition on the Acquisition of Covered Defense Telecommunications Equipment or Services -- Representation

MAY 2021

252.204-7018 Prohibition on the Acquisition of Covered Defense Telecommunications Equipment or Services

JAN 2023

252.204-7022 Expediting Contract Closeout MAY 2021 252.223-7006 Prohibition On Storage, Treatment, and Disposal of Toxic or

Hazardous Materials

SEP 2014

252.225-7001 Buy American and Balance of Payments Program FEB 2024 252.225-7002 Qualifying Country Sources As Subcontractors MAR 2022 252.225-7055 Representation Regarding Business Operations with the

Maduro Regime

MAY 2022

252.225-7056 Prohibition Regarding Business Operations with the Maduro Regime

JAN 2023

252.225-7059 Prohibition on Certain Procurements from the Xinjiang Uyghur Autonomous Region - Representation

JUN 2023

252.225-7060 Prohibition on Certain Procurements from the Xinjiang Uyghur Autonomous Region

JUN 2023

252.232-7003 Electronic Submission of Payment Requests and Receiving Reports

DEC 2018

252.232-7010 Levies on Contract Payments DEC 2006 252.243-7001 Pricing Of Contract Modifications DEC 1991 252.247-7023 Transportation of Supplies by Sea JAN 2023

CLAUSES INCORPORATED BY FULL TEXT

52.204-20 Predecessor of Offeror (AUG 2020)

(a) Definitions. As used in this provision--

Commercial and Government Entity (CAGE) code means--

(1) An identifier assigned to entities located in the United States or its outlying areas by the Defense Logistics Agency (DLA) Commercial and Government Entity (CAGE) Branch to identify a commercial or government entity by unique location; or

(2) An identifier assigned by a member of the North Atlantic Treaty Organization (NATO) or by the NATO Support and Procurement Agency (NSPA) to entities located outside the United States and its outlying areas that the DLA Commercial and Government Entity (CAGE) Branch records and maintains in the CAGE master file. This type of code is known as a NATO CAGE (NCAGE) code.

Predecessor means an entity that is replaced by a successor and includes any predecessors of the predecessor.

Successor means an entity that has replaced a predecessor by acquiring the assets and carrying out the affairs of the predecessor under a new name (often through acquisition or merger). The term “successor” does not include new offices/divisions of the same company or a company that only changes its name. The extent of the responsibility of the successor for the liabilities of the predecessor may vary, depending on State law and specific circumstances.

(b) The Offeror represents that it [____] is or [____] is not a successor to a predecessor that held a Federal contract or grant within the last three years.

(c) If the Offeror has indicated “is” in paragraph (b) of this provision, enter the following information for all predecessors that held a Federal contract or grant within the last three years (if more than one predecessor, list in reverse chronological order):

Predecessor CAGE code: ____ (or mark “Unknown”).

Predecessor legal name: ____.

(Do not use a “doing business as” name).

(End of provision)

52.204-24 REPRESENTATION REGARDING CERTAIN TELECOMMUNICATIONS AND VIDEO

SURVEILLANCE SERVICES OR EQUIPMENT (NOV 2021)

The Offeror shall not complete the representation at paragraph (d)(1) of this provision if the Offeror has represented that it "does not provide covered telecommunications equipment or services as a part of its offered products or services to the Government in the performance of any contract, subcontract, or other contractual instrument" in paragraph (c)(1) in the provision at 52.204-26, Covered Telecommunications Equipment or Services-- Representation, or in paragraph (v)(2)(i) of the provision at 52.212-3, Offeror Representations and Certifications- Commercial Products and Commercial Services. The Offeror shall not complete the representation in paragraph (d)(2) of this provision if the Offeror has represented that it "does not use covered telecommunications equipment or services, or any equipment, system, or service that uses covered telecommunications equipment or services" in paragraph (c)(2) of the provision at 52.204-26, or in paragraph (v)(2)(ii) of the provision at 52.212-3.

(a) Definitions. As used in this provision-

Backhaul, covered telecommunications equipment or services, critical technology, interconnection arrangements, reasonable inquiry, roaming, and substantial or essential component have the meanings provided in the clause 52.204-25, Prohibition on Contracting for Certain Telecommunications and Video Surveillance Services or Equipment.

(b) Prohibition.

(1) Section 889(a)(1)(A) of the John S. McCain National Defense Authorization Act for Fiscal Year 2019 (Pub. L.

115-232) prohibits the head of an executive agency on or after August 13, 2019, from procuring or obtaining, or extending or renewing a contract to procure or obtain, any equipment, system, or service that uses covered telecommunications equipment or services as a substantial or essential component of any system, or as critical technology as part of any system. Nothing in the prohibition shall be construed to--

(i) Prohibit the head of an executive agency from procuring with an entity to provide a service that connects to the facilities of a third-party, such as backhaul, roaming, or interconnection arrangements; or

(ii) Cover…