Z1DA--657A4-17-905, Replace Boilers Bldg 7 UST (VA-20-00011192)

PRE-PROPOSAL CONFERENCE OUTLINE

Introduction

Good afternoon, thank you for taking the time to attend this pre-solicitation conference.

Today we will first discuss contractual issues, then we will discuss technical issues and finally the Project Engineer (COR) will conduct a walk through of the areas.

Before we cover the issues, let me first introduce myself and the Government staff.

CO - Mike Bottary

COR - Donald "Mike" Wright

Other VA staff - /_ f.l't-JL.c,.. !) ( Av(,,...J

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Statement of Work 657A4-17-905 Page 16

Statement of Work

657A4-17-905

Remove / Replace Underground Storage Tanks

Scope of Work

This Statement of Work is for performance of work associated with Underground Storage Tanks for project 657A4-17-905.

A walkthrough will be held on site. Lack of attendance or omission of questions at the walkthrough shall not be subject to modification due to site conditions or details.

The contractor shall provide all services, materials, labor, supervision, safety, equipment, and expertise for items described in this document. Work is subject to IBC, IPC, RP8 (seismic), NFPA, IEEE, NETA/NECA, UL, ASTM, ASHRAE, MDNR, EPA and other similar applicable standards. The State of Missouri regulations are applicable and strictly enforced: https://dnr.mo.gov/env/hwp/ustchanges.htm. Upon completion, documentation/narrative is required from the contractor that all compliance has been achieved. The VHA Boiler Plant Directive 1810, most current edition, shall be the basis of requirements. All supporting Owner Project Requirements (OPR) and Basis of Design (BOD) documents are posted publicly on VHA s Technical Information Library (TIL).

Any deviations in required work items from this SoW shall come in the form of an RFI. The VA shall provide the Final Response for any approval or denial. The Contracting Officer (CO) is the only entity that can approve changes that impact the Scope of Work and Contract Cost. Any contractual changes shall be provided in writing from the CO.

The contractor shall provide shop drawings, construction period services, demolition, installation and environmental compliance oversite for the removal and replacement of the Underground Storage Tanks (USTs), associated with the Building 7 Boilers and Building 7 Generator for a 100% functional product.

The contractor shall provide the following deliverables for shop drawings:

Provide Shop Drawings indicating complete system connections and equipment layouts.

Shop Drawings shall be developed with 1-3 site investigations after Notice to Proceed. Drawing disciplines and minimum quantities are listed; subject to contractor for additional detail, etc.

Compliance Reference / General Conditions: 2 Drawings.

Demolition: 1 Drawing indicating removal of systems and their locations.

Site / Civil: 3 Drawings; 1 sheet for grade and force protection / physical security, 1 sheet for Boiler UST, and 1 sheet for Generator UST.

Mechanical / Plumbing: 4 Drawings.

Electrical / Instrumentation: 2 Drawings.

The contractor shall provide 2 full Shop Drawing review meetings; at the 35% milestone and the 75% milestone. The VA shall have 5 business days for reply and concurrence at each milestone.

The contractor shall review archive drawings on station as necessary to facilitate Shop Drawing documents.

The contractor provided construction deliverables are:

Remove existing Fuel Oil System entirely, less boiler fuel oil train. Demolition of pumps, piping, tanks, and all associated power / controls for the fuel oil system. Removal of the Building 7 Generator UST back to day tank interior connection.

Provide a cost per cubic yard for hazardous material removal, with adherence to the State of Missouri (MDNR) and Federal (EPA) regulations. Unknown/unforeseen quantities of contamination shall be assessed upon discovery. A modification will be issued after severity, quantities, and other salient characteristics are documented and proposed to the COR and CO. Contractor shall be responsible for any and all clean up, remediation, and removal from site of any contaminated or hazardous material. Modification pricing will be based upon the base bid cost per cubic yard with the determined quantity.

Install Missouri Department of Natural Resources / EPA Compliant / NFPA 30 - Underground Storage Tanks. The capacity of the tank(s) shall, at minimum, be sized for the fuel burn rate of the boilers in this project with mandatory self-sustaining peak heating day loading per VHA Boiler Plant Directive 1810 with an additional 10,000-gal capacity for storage of emergency preparedness generator fuel. The building 7 generator tank shall be sized for 96-hour, 100% loaded, run time per NFPA 110/101.

USTs and piping shall have all controls, fuel management, leak detection, fuel quality, level indication, filtration systems, and all other applicable required systems to provide a 100% functional system and delivery of fuel to Boilers and Generator at specified burn rates; coordinate with manufacturer and installing contractors as necessary. Veeder-Root or equal system. The contractor shall provide all IT hardware and software as required for a functional system. The system shall print reports, integrate to BAS, have audible alarm, and remotely notify staff.

N+1 redundant Fuel Oil Pumps and all associated items shall be on emergency power with filtration and isolation capabilities. The pumps shall be connected to a manifold with cross feed capabilities for fuel treatment introduction, fuel transfer between tanks, and fuel transfer to an external connection. The pumps shall be installed with spill protection provisions. The pumps shall be balanced for correct burner fuel delivery.

Provide Natural Gas Valve power on dedicated circuit. Provide TVSS in panel the valve is fed from.

Repair / replace impacted parking lot, curb, gutter, storm drainage to include any damage during construction. This shall take into consideration the VHA Physical Security Design manual requirements published on the TIL.

Provide compliant pipe trench in Building 7 for Fuel Oil Piping / drain requirements / oil water separator requirements and removal of lead paint on trench covers. Remove/demolish abandoned boiler tertiary system tanks to allow for space if required. Coordinate final location with COR as necessary.

Provide training and literature to operations staff of new systems.

Provide registrations of USTs with MDNR / EPA as required.

Provide appropriate fuel to full levels in all tanks. Coordinate with Medical Center COR.

All NEC/NFPA/MDNR/EPA and other applicable healthcare facility codes referred to in specification or VHA Publications such as VHA Directive 1028 / 1810 and Electrical / Mechanical / Plumbing Physical Security Design Manual are applicable to this project and will be strictly enforced. Seismic requirements published on the VA TIL and RP 8 are applicable. Any deviations or work that is non-conformant to standards, regulations, or specification shall be removed and corrected at no cost to the Government. The VA adopts the most current versions of applicable publications.

The contractor shall provide the Poplar Bluff VA Medical Center with the proper skilled labor, equipment, materials, supplies, and supervision for performance of all work indicated or referenced within this Statement of Work and by the corresponding Construction Documents (plans, specifications, VA TIL publications and other provided documents) for a 100% functional product upon completion.

Other Requirements

Provide secure fencing surrounding the staging area/construction trailer to prevent entry by unauthorized individuals or patients.

Protect the environment and structures that remain adjacent to the work area from damage. Any damage incurred adjacent to the work area will be repaired by the contractor at no cost to the Government.

Contractor is required to perform all hazardous material remediation and removal for this project as stated in the project drawings and specifications. Provide IH services where required.

Pay application shall be submitted in pencil copy to the COR prior to formal application for payment. The pencil copy shall be accompanied by certified payroll, job site sign in documentation, and any other time/attendance documentation relevant to the schedule of values.

The Government shall not pay for materials that are not on site or stored off site.

Provide submittals in accordance with Division 01 Master Specifications for all materials prior to installation. Additional submittals may be required at the request of the Contracting Officer or COR. A comparison of products for QA/QC may be requested by the COR and CO. The A/E or COR will approve/disapprove contractor submittals. Any submittal that is disapproved shall be addressed by the contractor in a timely manner but no less than five (5) days. If more time is needed to address disapproved submittals, the contractor may request, in writing, for additional time from the COR.

The COR will provide inspection and acceptance of the work on behalf of the Contracting Officer. Any work that is to be enclosed (earth, concrete, etc.) shall be inspected by the COR prior to covering. All work shall be accepted by the COR on behalf of the Contracting Officer. Any work that is found to be unacceptable by the COR shall be removed and replaced at no cost to the Government. Workmanship/quality of work is subject to acceptance.

The contractor shall reduce facility impact and plan accordingly. The contractor shall give 14 calendar days of notice for interruption of any service. The contractor shall phase, and plan work accordingly, including but not limited to performing work outside of normal operating hours, weekends, holidays, and shift work.

Provide a 1-year warranty on all items within scope.

Provide temporary Fuel Oil storage on site for 1 boiler in an emergency. Coordinate with facility for connection. Polish existing fuel oil to be retained and store temporarily.

Existing Conditions

The Contractor shall verify all areas requiring work as stated in this Statement of Work prior to the commencement of work.

The Contractor shall coordinate with all other contractors on site. Coordination with, in, and around the following projects are required:

657-401

657-400

657-351

657A4-15-111

657A4-17-902

657A4-19-101

657A4-19-609

657A4-19-103

657A4-19-800

657A4-19-210

657A4-19-300

Other Projects and Operations noted in weekly coordination meetings

Safety/Infection Control/Security

The Contractor is responsible for work site safety. The Contractor shall implement a safety program that protects the lives and health of personnel inside and immediately surrounding the work area, prevents damage to property, and avoids normal work or patient flow interruptions. The Contractor shall provide an OSHA certified Competent Person onsite at all times while work is being performed, erect appropriate safety barricades, signs, signal lights, etc. as well as comply with the requirements of all Federal, State, and Local safety laws, rules, and regulations. The SSHO shall make all requests for Hot Work, Energized Work, Trenching/Excavation, Hoisting/Craning, or any other applicable permit 1 day in advance. Coordinate with Safety Service as necessary. Contractors shall participate in TB testing and Flu vaccinations prior to commencement of work. Reference VHA Directive 1192.

The Contractor shall follow the requirements of the Infection Control Risk Assessment. Privacy and safety training shall be completed by all contractor personnel prior to the commencement of work. TB and other infectious disease immunization/testing are required. Flu Shots are required for contractor personnel.

Test and Performance

The Contractor shall notify the Contracting Officer s Representative one (1) week in advance of any performance, inspection or acceptance tests that are to be conducted. The tests shall be performed in the presence of the Contracting Officer s Representative. Any work that has been covered or has not been properly tested by visual inspection will be removed and replaced at no additional cost to the Government. Failure of tests shall require retest or replacement at no cost to the Government.

Schedule of Work

The Contractor shall discuss work hours with the Contraction Officer s Representative prior to the commencement of work. Normal working hours shall be from 7:00 am to 5:00 pm. The Contractor and Contracting Officer s Representative will agree on the hours of operations for this scope of work. The Contractor is responsible for notifying VA Police of the time, location, and work to be performed before every off-hour engagement. Major interruptions to the facility with a duration of over 4 hours are subject to Nights and Weekends only.

Period of Performance

The period of performance is 270 calendar days after the Notice to Proceed.

Liability of Contractor

Any damage to Government property caused by the Contractor shall be repaired or replaced by the Contractor at no cost to the Government.

The Contractor shall not disconnect any service or utilities without prior approval of the COR. No less than a two (2) weeks of notice shall be given to the COR if interruption is needed. The Government will not be held liable for any costs incurred due to time constraints needed for service or utility interruptions.

Labor Laws

The Davis-Bacon Act applies to this project.

Site Cleanup and Restoration

The Contractor shall remove waste generated every day from the worksite. Waste shall be deposited in an appropriate dumpster provided by the Contractor and located in an area approved by the COR and removed from the grounds every week or when full. The Contractor is responsible for the procurement of waste services, and no Government leased, or owned dumpster shall be used to dispose of construction waste.

All recyclable materials shall be recycled at appropriate facilities. Invoices or receipts related to the recycling of construction waste shall be submitted to the Contracting Officer s Representative.

The Government has first right of refusal. The contractor shall relocate items retained by the Government for storage.

Execution

The Contractor will perform all work and provide the labor and equipment needed to meet deliverables within this Statement of Work. The Government shall not loan or provide any labor or equipment. The Government is not responsible for costs incurred due to mismanagement of labor or lack of proper equipment.

Attachments/References

Missouri Department of Natural Resources: https://dnr.mo.gov/env/hwp/docs/MissouriMustsforUSTs.pdf

VA CEOSH (Internal) VHA Directive 1810: http://vaww.ceosh.med.va.gov/01HE/02HE_SpecificTopics/03HE_BoilerPlants/04HE_VA_Policies_DUSHOMItems/VHA%20Directive_1810%20BOILER%20AND%20BOILER%20PLANT%20OPERATIONS_2017-02-06.pdf

VHA Technical Information Library: https://www.cfm.va.gov/til/

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VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE FOR INCLUSION INTO CONTRACTS

GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

A contractor/subcontrator shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

VA INFORMATION CUSTODIAL LANGUAGE

Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

If VA determines that the contractor has violated any of the information confidentiality, privacy, security, and other provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

SECURITY INCIDENT INVESTIGATION

The term security incident means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

To the extent known by the contractor/subcontractor, the contractor/subcontractor s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

LIQUIDATED DAMAGES FOR DATA BREACH

Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

The contractor/subcontractor shall provide notice to VA of a security incident as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

Each risk analysis shall address all relevant information concerning the data breach, including the following:

Nature of the event (loss, theft, unauthorized access);

Description of the event, including:

(a) date of occurrence;

(b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code;

(3) Number of individuals affected or potentially affected;

(4) Names of individuals or groups affected or potentially affected;

(5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;

(6) Amount of time the data has been out of VA control;

(7) The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons);

(8) Known misuses of data containing sensitive personal information, if any;

(9) Assessment of the potential harm to the affected individuals;

(10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and

(11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.

Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $__37.50__ per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

(1) Notification;

(2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;

(3) Data breach analysis;

(4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;

(5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and

(6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.

TRAINING

All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

Successfully complete the appropriate VA privacy training and annually complete required privacy training (See below training); and

Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access

The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

Failure to complete the mandatory annual training, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

7. ADDITIONAL REQUIREMENTS

a. The COR is responsible for coordinating with the Police prior to contractor arrival to identify the names of contractor personnel so that Police can ensure sufficient number of contractor badges are available for issuance prior to beginning work. COR is also responsible for signing out and signing in temporary contractor badges.

b. The COR is also responsible for maintaining copies of signed Privacy training for all contractors according to RCS 10-1.

c. Any work performed outside of official VA business hours after hours will require escorts.

d. Escort duties for un-cleared contractors are strictly limited to government officials, specifically VA employees. At no time are contractors allowed to escort other contractors.

VA Privacy Training for Personnel without Access to VA Computer Systems

or Direct Access or Use to VA Sensitive Information

The Department of Veterans Affairs, VA must comply with all applicable privacy and confidentiality statutes and regulations. One of the requirements in VA is to have all personnel trained annually on privacy requirements. Privacy represents what must be protected by VA in the collection, use, and disclosure of personal information whether the medium is electronic, paper or verbal.

This document satisfies the basic privacy training requirement for a contractor, volunteer, or other personnel only if the individual does not use or have access to any VA computer system such as Time and Attendance, PAID, CPRS, VistA Web, VA sensitive information or protected health information (PHI), whether paper or electronic. You will find this training outlines your roles and responsibility for protecting VA sensitive information (medical, financial, or educational) that you may incidentally or accidentally see or overhear.

If you have direct access to protected health information or access to a VA computer system where there is protected health information such as CPRS, VistA Web, you must take Privacy and HIPAA Focused Training (TMS 10203). VA Privacy and Information Security Awareness and Rules of Behavior (TMS 10176) is always required in order to use or gain access to a VA computer systems or VA sensitive information, whether or not protected health information is included. Both trainings are located within the VA Talent Management System (TMS): https://www.tms.va.gov

What is VA Sensitive Information/Data?

All Department information and/or data on any storage media or in any form or format, which requires protection due to the risk of harm that could result from inadvertent or deliberate disclosure, alteration, or destruction of the information. The term includes not only information that identifies an individual but also other information whose improper use or disclosure could adversely affect the ability of an agency to accomplish its mission, proprietary information, and records about individuals requiring protection under applicable confidentiality provisions.

What is Protected Health Information?

The HIPAA Privacy Rule defines protected health information as Individually Identifiable Health Information transmitted or maintained in any form or medium by a covered entity, such as VHA.

What is an Incidental Disclosure?

An incidental disclosure is one where an individual s information may be disclosed incidentally even though appropriate safeguards are in place. Due to the nature of VA communications and practices, as well as the various environments in which Veterans receive healthcare or other services from VA, the potential exists for a Veteran s protected health information or VA sensitive information to be disclosed incidentally.

For example:

You overhear a healthcare provider s conversation with another provider or patient even when the conversation is taken place appropriately.

You may see limited Veteran information on sign-in sheets or white boards within a treating area of the facility.

Hearing a Veteran s name being called out for an appointment or when the Veteran is being transported/escorted to and from an appointment.

Safeguards You Must Follow To Secure VA Sensitive Information:

Secure any VA sensitive information found in unsecured public areas (parking lot, trash can, or vacated area) until information can be given to your supervisor or Privacy Officer. You must report such incidents to your Privacy Officer timely.

Don t take VA sensitive information off facilities grounds without VA permission unless the VA information is general public information, i.e., brochures/pamphlets.

Don t take pictures using a personal camera without the permission from the Medical Center Director.

Any protected health information overheard or seen in VA should not be discussed or shared with anyone who does not have a need to know the information in the performance of their official job duties, this includes spouses, employers or colleagues.

Do not share VA access cards, keys, or codes to enter the facility.

Immediately report lost or stolen Personal Identity Verification (PIV) or Veteran Health Identification Cards (VHIC), any VA keys or keypad lock codes to your supervisor or VA police.

Do not use a VA computer using another VA employee s access and password.

Do not ask another VA employee to access your own protected health information. You must request this information in writing from the Release of Information section at your facility.

What are the Six Privacy Laws and Statutes Governing VA?

Freedom of Information Act (FOIA) compels disclosure of reasonably described VA records or a reasonably segregated portion of the records to any person upon written request unless one or more of the nine exemptions apply.

Privacy Act of 1974 provides for the confidentiality of personal information about a living individual who is a United States citizen or an alien lawfully admitted to U.S. and whose information is retrieved by the individual s name or other unique identifier, e.g. Social Security Number.

Health Insurance Portability and Accountability Act (HIPAA) provides for the improvement of the efficiency and effectiveness of health care systems by encouraging the development of health information systems through the establishment of standards and requirements for the electronic transmission, privacy, and security of certain health information.

38 U.S.C. 5701 provides for the confidentiality of all VA patient and claimant information, with special protection for their names and home addresses.

38 U.S.C. 7332 provides for the confidentiality of drug abuse, alcoholism and alcohol abuse, infection with the human immunodeficiency virus (HIV) and sickle cell anemia medical records and health information.

38 U.S.C. 5705 provides for the confidentiality of designated medical-quality assurance documents.

What are the Privacy Rules Concerning Use and Disclosure?

You are not authorized to use or disclose protected health information. In general, VHA personnel may only use information for purposes of treatment, payment or healthcare operations when they have a need-to-know in the course of their official job duties. VHA may only disclose protected health information upon written request by the individual who is the subject of the information or as authorized by law.

How is Privacy Enforced?

There are both civil and criminal penalties, including monetary penalties that may be imposed if a privacy violation has taken place. Any willful negligent or intentional violation of an individual s privacy by VA personnel, contract staff, volunteers, or others may result in such corrective action as deemed appropriate by VA including the potential loss of employment, contract, or volunteer status.

Know your VA/VHA Privacy Officer and Information Security Officer. These are the individuals to whom you can report any potential violation of protected health information or VA sensitive information, or any other concerns regarding privacy of VA sensitive information.

YOU ARE RESPONSIBLE FOR PROTECTING THE CONFIDENTIAL INFORMATION OF OUR VETERANS

__________________________________________ ________________

Employee (Print Name) Date

__________________________________________

Employee Signature

__________________________________________

Print Name of Contract Agency, if contractor

__________________________________________

Print Name of VHA Department/Supervisor/Local COR

PROVIDE A COPY OF THIS FORM TO YOUR SUPERVISOR/LOCAL COR

FOR DATA ENTRY INTO TALENT MANAGEMENT SYSTEM

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RECORDS MANAGEMENT OBLIGATIONS

1. APPLICABILITY

This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

2. DEFINITIONS

Federal Record as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

The term Federal record:

a. includes Department of Veterans Affairs, Veterans Health Administration records.

b. does not include personal materials.

c. applies to records created, received, or maintained by Contractors pursuant to their Department of Veterans Affairs, Veterans Health Administration contract.

d. may include deliverables and documentation associated with deliverables.

3. REQUIREMENTS

a. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

b. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

c. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

d. John J. Pershing VA Medical Center and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of John J. Pershing VA Medical Center or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701.

In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to John J. Pershing VA Medical Center. The agency must report promptly to NARA in accordance with 36 CFR 1230.

e. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to John J. Pershing VA Medical Center s control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

f. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and John J. Pershing VA Medical Center s guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

g. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with John J. Pershing VA Medical Center s policy.

h. The Contractor shall not create or maintain any records containing any non-public John J. Pershing VA Medical Center s information that are not specifically tied to or authorized by the contract.

i. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

j. The John J. Pershing VA Medical Center owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which John J. Pershing VA Medical Center shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

k. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

4. FLOWDOWN OF REQUIREMENTS TO SUBCONTRACTORS

a. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract, and require written subcontractor acknowledgment of same.

b. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

Statement of Work 657A4-17-905 Page 16

Statement of Work

657A4-17-905

Remove / Replace Underground Storage Tanks

Scope of Work

This Statement of Work is for performance of work associated with Underground Storage Tanks for project 657A4-17-905.

A walkthrough will be held on site. Lack of attendance or omission of questions at the walkthrough shall not be subject to modification due to site conditions or details.

The contractor shall provide all services, materials, labor, supervision, safety, equipment, and expertise for items described in this document. Work is subject to IBC, IPC, RP8 (seismic), NFPA, IEEE, NETA/NECA, UL, ASTM, ASHRAE, MDNR, EPA and other similar applicable standards. The State of Missouri regulations are applicable and strictly enforced: https://dnr.mo.gov/env/hwp/ustchanges.htm. Upon completion, documentation/narrative is required from the contractor that all compliance has been achieved. The VHA Boiler Plant Directive 1810, most current edition, shall be the basis of requirements. All supporting Owner Project Requirements (OPR) and Basis of Design (BOD) documents are posted publicly on VHA s Technical Information Library (TIL).

Any deviations in required work items from this SoW shall come in the form of an RFI. The VA shall provide the Final Response for any approval or denial. The Contracting Officer (CO) is the only entity that can approve changes that impact the Scope of Work and Contract Cost. Any contractual changes shall be provided in writing from the CO.

The contractor shall provide professional design documents, construction period services, demolition, installation and environmental compliance oversite for the removal and replacement of the Underground Storage Tanks (USTs), associated with the Building 7 Boilers and Building 7 Generator for a 100% functional product.

The contractor shall provide planning phase deliverables and construction phase deliverable as described below.

The contractor provided planning deliverables are:

Provide Professional Engineering Services (Specifications and Drawings) to facilitate construction deliverables within this SoW.

Specifications shall be developed from VHA s TIL, specifically PG-18-1 Master Specifications conforming with Design and Construction Procedures in short form PG-18-3.

Provide procure or equal submittal and design document exchange site for electronic record management for planning and construction phases.

Drawings shall be developed with 1-3 site investigations after Notice to Proceed. Drawing disciplines and minimum quantities are listed; subject to designer for additional detail, etc.

Cover Sheet / Compliance Reference / General Conditions: Specifications and 2 Drawings.

Demolition: Specifications and 1 Drawing indicating removal of systems and their locations.

Site / Civil: Specifications and 3 Drawings; 1 sheet for grade and force protection / physical security, 1 sheet for Boiler UST, and 1 sheet for Generator UST.

Mechanical / Plumbing: Specifications and 4 Drawings.

Electrical / Instrumentation: Specifications and 2 Drawings.

The contractor shall provide 2 full document review meetings; at the 35% planning milestone and the 75% planning milestone. The VA shall have 5 business days for reply and concurrence at each milestone.

The designers shall review archive drawings on station as necessary to facilitate planning documents.

Provide Construction Period Services for Construction. 3 site visits for a 4-hour minimum. Provide first level submittal review; final approval from VA.

The contractor provided construction deliverables are:

Remove existing Fuel Oil System entirely, less boiler fuel oil train. Demolition of pumps, piping, tanks, and all associated power / controls for the fuel oil system. Removal of the Building 7 Generator UST back to day tank interior connection.

Provide a cost per cubic yard for hazardous material removal, with adherence to the State of Missouri (MDNR) and Federal (EPA) regulations. Unknown/unforeseen quantities of contamination shall be assessed upon discovery. A modification will be issued after severity, quantities, and other salient characteristics are documented and proposed to the COR and CO. Contractor shall be responsible for any and all clean up, remediation, and removal from site of any contaminated or hazardous material. Modification pricing will be based upon the base bid cost per cubic yard with the determined quantity.

Install Missouri Department of Natural Resources / EPA Compliant / NFPA 30 - Underground Storage Tanks. The capacity of the tank(s) shall, at minimum, be sized for the fuel burn rate of the boilers in this project with mandatory self-sustaining peak heating day loading per VHA Boiler Plant Directive 1810 with an additional 10,000-gal capacity for storage of emergency preparedness generator fuel. The building 7 generator tank shall be sized for 96-hour, 100% loaded, run time per NFPA 110/101.

USTs and piping shall have all controls, fuel management, leak detection, fuel quality, level indication, filtration systems, and all other applicable required systems to provide a 100% functional system and delivery of fuel to Boilers and Generator at specified burn rates; coordinate with manufacturer and installing contractors as necessary. Veeder-Root or equal system. The contractor shall provide all IT hardware and software as required for a functional system. The system shall print reports, integrate to BAS, have audible alarm, and remotely notify staff.

N+1 redundant Fuel Oil Pumps and all associated items shall be on emergency power with filtration and isolation capabilities. The pumps shall be connected to a manifold with cross feed capabilities for fuel treatment introduction, fuel transfer between tanks, and fuel transfer to an external connection. The pumps shall be installed with spill protection provisions. The pumps shall be balanced for correct burner fuel delivery.

Provide Natural Gas Valve power on dedicated circuit. Provide TVSS in panel the valve is fed from.

Repair / replace impacted parking lot, curb, gutter, storm drainage to include any damage during construction. This shall take into consideration the VHA Physical Security Design manual requirements published on the TIL.

Provide compliant pipe trench in Building 7 for Fuel Oil Piping / drain requirements / oil water separator requirements and removal of lead paint on trench covers. Remove/demolish abandoned boiler tertiary system tanks to allow for space if required. Coordinate final location with COR as necessary.

Provide training and literature to operations staff of new systems.

Provide registrations of USTs with MDNR / EPA as required.

Provide appropriate fuel to full levels in all tanks. Coordinate with Medical Center COR.

All NEC/NFPA/MDNR/EPA and other applicable healthcare facility codes referred to in specification or VHA Publications such as VHA Directive 1028 / 1810 and Electrical / Mechanical / Plumbing Physical Security Design Manual are applicable to this project and will be strictly enforced. Seismic requirements published on the VA TIL and RP 8 are applicable. Any deviations or work that is non-conformant to standards, regulations, or specification shall be removed and corrected at no cost to the Government. The VA adopts the most current versions of applicable publications.

The contractor shall provide the Poplar Bluff VA Medical Center with the proper skilled labor, equipment, materials, supplies, and supervision for performance of all work indicated or referenced within this Statement of Work and by the corresponding Construction Documents (plans, specifications, VA TIL publications and other provided documents) for a 100% functional product upon completion.

Other Requirements

Provide secure fencing surrounding the staging area/construction trailer to prevent entry by unauthorized individuals or patients.

Protect the environment and structures that remain adjacent to the work area from damage. Any damage incurred adjacent to the work area will be repaired by the contractor at no cost to the Government.

Contractor is required to perform all hazardous material remediation and removal for this project as stated in the project drawings and specifications. Provide IH services where required.

Pay application shall be submitted in pencil copy to the COR prior to formal application for payment. The pencil copy shall be accompanied by certified payroll, job site sign in documentation, and any other time/attendance documentation relevant to the schedule of values.

The Government shall not pay for materials that are not on site or stored off site.

Provide submittals in accordance with Division 01 Master Specifications for all materials prior to installation. Additional submittals may be required at the request of the Contracting Officer or COR. A comparison of products for QA/QC may be requested by the COR and CO. The A/E or COR will approve/disapprove contractor submittals. Any submittal that is disapproved shall be addressed by the contractor in a timely manner but no less than five (5) days. If more time is needed to address disapproved submittals, the contractor may request, in writing, for additional time from the COR.

The COR will provide inspection and acceptance of the work on behalf of the Contracting Officer. Any work that is to be enclosed (earth, concrete, etc.) shall be inspected by the COR prior to covering. All work shall be accepted by the COR on behalf of the Contracting Officer. Any work that is found to be unacceptable by the COR shall be removed and replaced at no cost to the Government. Workmanship/quality of work is subject to acceptance.

The contractor shall reduce facility impact and plan accordingly. The contractor shall give 14 calendar days of notice for interruption of any service. The contractor shall phase, and plan work accordingly, including but not limited to performing work outside of normal operating hours, weekends, holidays, and shift work.

Provide a 1-year warranty on all items within scope.

Provide temporary Fuel Oil storage on site for 1 boiler in an emergency. Coordinate with facility for connection. Polish existing fuel oil to be retained and store temporarily.

Existing Conditions

The Contractor shall verify all areas requiring work as stated in this Statement of Work prior to the commencement of work.

The Contractor shall coordinate with all other contractors on site. Coordination with, in, and around the following projects are required:

657-401

657-400

657-351

657A4-15-111

657A4-17-902

657A4-19-101

657A4-19-609

657A4-19-103

657A4-19-800

657A4-19-210

657A4-19-300

Other Projects and Operations noted in weekly coordination meetings

Safety/Infection Control/Security

The Contractor is responsible for work site safety. The Contractor shall implement a safety program that protects the lives and health of personnel inside and immediately surrounding the work area, prevents damage to property, and avoids normal work or patient flow interruptions. The Contractor shall provide an OSHA certified Competent Person onsite at all times while work is being performed, erect appropriate safety barricades, signs, signal lights, etc. as well as comply with the requirements of all Federal, State, and Local safety laws, rules, and regulations. The SSHO shall make all requests for Hot Work, Energized Work, Trenching/Excavation, Hoisting/Craning, or any other applicable permit 1 day in advance. Coordinate with Safety Service as necessary. Contractors shall participate in TB testing and Flu vaccinations prior to commencement of work. Reference VHA Directive 1192.

The Contractor shall follow the requirements of the Infection Control Risk Assessment. Privacy and safety training shall be completed by all contractor personnel prior to the commencement of work. TB and other infectious disease immunization/testing are required. Flu Shots are required for contractor personnel.

Test and Performance

The Contractor shall notify the Contracting Officer s Representative one (1) week in advance of any performance, inspection or acceptance tests that are to be conducted. The tests shall be performed in the presence of the Contracting Officer s Representative. Any work that has been covered or has not been properly tested by visual inspection will be removed and replaced at no additional cost to the Government. Failure of tests shall require retest or replacement at no cost to the Government.

Schedule of Work

The Contractor shall discuss work hours with the Contraction Officer s Representative prior to the commencement of work. Normal working hours shall be from 7:00 am to 5:00 pm. The Contractor and Contracting Officer s Representative will agree on the hours of operations for this scope of work. The Contractor is responsible for notifying VA Police of the time, location, and work to be performed before every off-hour engagement. Major interruptions to the facility with a duration of over 4 hours are subject to Nights and Weekends only.

Period of Performance

The period of performance is 270 calendar days after the Notice to Proceed.

Liability of Contractor

Any damage to Government property caused by the Contractor shall be repaired or replaced by the Contractor at no cost to the Government.

The Contractor shall not disconnect any service or utilities without prior approval of the COR. No less than a two (2) weeks of notice shall be given to the COR if interruption is needed. The Government will not be held liable for any costs incurred due to time constraints needed for service or utility interruptions.

Labor Laws

The Davis-Bacon Act applies to this project.

Site Cleanup and Restoration

The Contractor shall remove waste generated every day from the worksite. Waste shall be deposited in an appropriate dumpster provided by the Contractor and located in an area approved by the COR and removed from the grounds every week or when full. The Contractor is responsible for the procurement of waste services, and no Government leased, or owned dumpster shall be used to dispose of construction waste.

All recyclable materials shall be recycled at appropriate facilities. Invoices or receipts related to the recycling of construction waste shall be submitted to the Contracting Officer s Representative.

The Government has first right of refusal. The contractor shall relocate items retained by the Government for storage.

Execution

The Contractor will perform all work and provide the labor and equipment needed to meet deliverables within this Statement of Work. The Government shall not loan or provide any labor or equipment. The Government is not responsible for costs incurred due to mismanagement of labor or lack of proper equipment.

Attachments/References

Missouri Department of Natural Resources: https://dnr.mo.gov/env/hwp/docs/MissouriMustsforUSTs.pdf

VA CEOSH (Internal) VHA Directive 1810: http://vaww.ceosh.med.va.gov/01HE/02HE_SpecificTopics/03HE_BoilerPlants/04HE_VA_Policies_DUSHOMItems/VHA%20Directive_1810%20BOILER%20AND%20BOILER%20PLANT%20OPERATIONS_2017-02-06.pdf

VHA Technical Information Library: https://www.cfm.va.gov/til/

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VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE FOR INCLUSION INTO CONTRACTS

GENERAL

Contractors, contractor personnel, subcontractors, and subcontractor personnel shall be subject to the same Federal laws, regulations, standards, and VA Directives and Handbooks as VA and VA personnel regarding information and information system security.

ACCESS TO VA INFORMATION AND VA INFORMATION SYSTEMS

A contractor/subcontrator shall request logical (technical) or physical access to VA information and VA information systems for their employees, subcontractors, and affiliates only to the extent necessary to perform the services specified in the contract, agreement, or task order.

The contractor or subcontractor must notify the Contracting Officer immediately when an employee working on a VA system or with access to VA information is reassigned or leaves the contractor or subcontractor s employ. The Contracting Officer must also be notified immediately by the contractor or subcontractor prior to an unfriendly termination.

VA INFORMATION CUSTODIAL LANGUAGE

Information made available to the contractor or subcontractor by VA for the performance or administration of this contract or information developed by the contractor/subcontractor in performance or administration of the contract shall be used only for those purposes and shall not be used in any other way without the prior written agreement of the VA. This clause expressly limits the contractor/subcontractor's rights to use data as described in Rights in Data - General, FAR 52.227-14(d) (1).

If VA determines that the contractor has violated any of the information confidentiality, privacy, security, and other provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under Federal Acquisition Regulation (FAR) part 12.

SECURITY INCIDENT INVESTIGATION

The term security incident means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

To the extent known by the contractor/subcontractor, the contractor/subcontractor s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

LIQUIDATED DAMAGES FOR DATA BREACH

Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

The contractor/subcontractor shall provide notice to VA of a security incident as set forth in the Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

Each risk analysis shall address all relevant information concerning the data breach, including the following:

Nature of the event (loss, theft, unauthorized access);

Description of the event, including:

(a) date of occurrence;

(b) data elements involved, including any PII, such as full name, social security number, date of birth, home address, account number, disability code;

(3) Number of individuals affected or potentially affected;

(4) Names of individuals or groups affected or potentially affected;

(5) Ease of logical data access to the lost, stolen or improperly accessed data in light of the degree of protection for the data, e.g., unencrypted, plain text;

(6) Amount of time the data has been out of VA control;

(7) The likelihood that the sensitive personal information will or has been compromised (made accessible to and usable by unauthorized persons);

(8) Known misuses of data containing sensitive personal information, if any;

(9) Assessment of the potential harm to the affected individuals;

(10) Data breach analysis as outlined in 6500.2 Handbook, Management of Security and Privacy Incidents, as appropriate; and

(11) Whether credit protection services may assist record subjects in avoiding or mitigating the results of identity theft based on the sensitive personal information that may have been compromised.

Based on the determinations of the independent risk analysis, the contractor shall be responsible for paying to the VA liquidated damages in the amount of $__37.50__ per affected individual to cover the cost of providing credit protection services to affected individuals consisting of the following:

(1) Notification;

(2) One year of credit monitoring services consisting of automatic daily monitoring of at least 3 relevant credit bureau reports;

(3) Data breach analysis;

(4) Fraud resolution services, including writing dispute letters, initiating fraud alerts and credit freezes, to assist affected individuals to bring matters to resolution;

(5) One year of identity theft insurance with $20,000.00 coverage at $0 deductible; and

(6) Necessary legal expenses the subjects may incur to repair falsified or damaged credit records, histories, or financial affairs.

TRAINING

All contractor employees and subcontractor employees requiring access to VA information and VA information systems shall complete the following before being granted access to VA information and its systems:

Successfully complete the appropriate VA privacy training and annually complete required privacy training (See below training); and

Successfully complete any additional cyber security or privacy training, as required for VA personnel with equivalent information system access

The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates for each applicable employee within 1 week of the initiation of the contract and annually thereafter, as required.

Failure to complete the mandatory annual training, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

7. ADDITIONAL REQUIREMENTS

a. The COR is responsible for coordinating with the Police prior to contractor arrival to identify the names of contractor personnel so that Police can ensure sufficient number of contractor badges are available for issuance prior to beginning work. COR is also responsible for signing out and signing in temporary contractor badges.

b. The COR is also responsible for maintaining copies of signed Privacy training for all contractors according to RCS 10-1.

c. Any work performed outside of official VA business hours after hours will require escorts.

d. Escort duties for un-cleared contractors are strictly limited to government officials, specifically VA employees. At no time are contractors allowed to escort other contractors.

VA Privacy Training for Personnel without Access to VA Computer Systems

or Direct Access or Use to VA Sensitive Information

The Department of Veterans Affairs, VA must comply with all applicable privacy and confidentiality statutes and regulations. One of the requirements in VA is to have all personnel trained annually on privacy requirements. Privacy represents what must be protected by VA in the collection, use, and disclosure of personal information whether the medium is electronic, paper or verbal.

This document satisfies the basic privacy training requirement for a contractor, volunteer, or other personnel only if the individual does not use or have access to any VA computer system such as Time and Attendance, PAID, CPRS, VistA Web, VA sensitive information or protected health information (PHI), whether paper or electronic. You will find this training outlines your roles and responsibility for protecting VA sensitive information (medical, financial, or educational) that you may incidentally or accidentally see or overhear.

If you have direct access to protected health information or access to a VA computer system where there is protected health information such as CPRS, VistA Web, you must take Privacy and HIPAA Focused Training (TMS 10203). VA Privacy and Information Security Awareness and Rules of Behavior (TMS 10176) is always required in order to use or gain access to a VA computer systems or VA sensitive information, whether or not protected health information is included. Both trainings are located within the VA Talent Management System (TMS): https://www.tms.va.gov

What is VA Sensitive Information/Data?

All Department information and/or data on any storage media or in any form or format, which requires protection due to the risk of harm that could result from inadvertent or deliberate disclosure, alteration, or destruction of the information. The term includes not only information that identifies an individual but also other information whose improper use or disclosure could adversely affect the ability of an agency to accomplish its mission, proprietary information, and records about individuals requiring protection under applicable confidentiality provisions.

What is Protected Health Information?

The HIPAA Privacy Rule defines protected health information as Individually Identifiable Health Information transmitted or maintained in any form or medium by a covered entity, such as VHA.

What is an Incidental Disclosure?

An incidental disclosure is one where an individual s information may be disclosed incidentally even though appropriate safeguards are in place. Due to the nature of VA communications and practices, as well as the various environments in which Veterans receive healthcare or other services from VA, the potential exists for a Veteran s protected health information or VA sensitive information to be disclosed incidentally.

For example:

You overhear a healthcare provider s conversation with another provider or patient even when the conversation is taken place appropriately.

You may see limited Veteran information on sign-in sheets or white boards within a treating area of the facility.

Hearing a Veteran s name being called out for an appointment or when the Veteran is being transported/escorted to and from an appointment.

Safeguards You Must Follow To Secure VA Sensitive Information:

Secure any VA sensitive information found in unsecured public areas (parking lot, trash can, or vacated area) until information can be given to your supervisor or Privacy Officer. You must report such incidents to your Privacy Officer timely.

Don t take VA sensitive information off facilities grounds without VA permission unless the VA information is general public information, i.e., brochures/pamphlets.

Don t take pictures using a personal camera without the permission from the Medical Center Director.

Any protected health information overheard or seen in VA should not be discussed or shared with anyone who does not have a need to know the information in the performance of their official job duties, this includes spouses, employers or colleagues.

Do not share VA access cards, keys, or codes to enter the facility.

Immediately report lost or stolen Personal Identity Verification (PIV) or Veteran Health Identification Cards (VHIC), any VA keys or keypad lock codes to your supervisor or VA police.

Do not use a VA computer using another VA employee s access and password.

Do not ask another VA employee to access your own protected health information. You must request this information in writing from the Release of Information section at your facility.

What are the Six Privacy Laws and Statutes Governing VA?

Freedom of Information Act (FOIA) compels disclosure of reasonably described VA records or a reasonably segregated portion of the records to any person upon written request unless one or more of the nine exemptions apply.

Privacy Act of 1974 provides for the confidentiality of personal information about a living individual who is a United States citizen or an alien lawfully admitted to U.S. and whose information is retrieved by the individual s name or other unique identifier, e.g. Social Security Number.

Health Insurance Portability and Accountability Act (HIPAA) provides for the improvement of the efficiency and effectiveness of health care systems by encouraging the development of health information systems through the establishment of standards and requirements for the electronic transmission, privacy, and security of certain health information.

38 U.S.C. 5701 provides for the confidentiality of all VA patient and claimant information, with special protection for their names and home addresses.

38 U.S.C. 7332 provides for the confidentiality of drug abuse, alcoholism and alcohol abuse, infection with the human immunodeficiency virus (HIV) and sickle cell anemia medical records and health information.

38 U.S.C. 5705 provides for the confidentiality of designated medical-quality assurance documents.

What are the Privacy Rules Concerning Use and Disclosure?

You are not authorized to use or disclose protected health information. In general, VHA personnel may only use information for purposes of treatment, payment or healthcare operations when they have a need-to-know in the course of their official job duties. VHA may only disclose protected health information upon written request by the individual who is the subject of the information or as authorized by law.

How is Privacy Enforced?

There are both civil and criminal penalties, including monetary penalties that may be imposed if a privacy violation has taken place. Any willful negligent or intentional violation of an individual s privacy by VA personnel, contract staff, volunteers, or others may result in such corrective action as deemed appropriate by VA including the potential loss of employment, contract, or volunteer status.

Know your VA/VHA Privacy Officer and Information Security Officer. These are the individuals to whom you can report any potential violation of protected health information or VA sensitive information, or any other concerns regarding privacy of VA sensitive information.

YOU ARE RESPONSIBLE FOR PROTECTING THE CONFIDENTIAL INFORMATION OF OUR VETERANS

__________________________________________ ________________

Employee (Print Name) Date

__________________________________________

Employee Signature

__________________________________________

Print Name of Contract Agency, if contractor

__________________________________________

Print Name of VHA Department/Supervisor/Local COR

PROVIDE A COPY OF THIS FORM TO YOUR SUPERVISOR/LOCAL COR

FOR DATA ENTRY INTO TALENT MANAGEMENT SYSTEM

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RECORDS MANAGEMENT OBLIGATIONS

1. APPLICABILITY

This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

2. DEFINITIONS

Federal Record as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the United States Government or because of the informational value of data in them.

The term Federal record:

a. includes Department of Veterans Affairs, Veterans Health Administration records.

b. does not include personal materials.

c. applies to records created, received, or maintained by Contractors pursuant to their Department of Veterans Affairs, Veterans Health Administration contract.

d. may include deliverables and documentation associated with deliverables.

3. REQUIREMENTS

a. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

b. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

c. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

d. John J. Pershing VA Medical Center and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of John J. Pershing VA Medical Center or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701.

In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to John J. Pershing VA Medical Center. The agency must report promptly to NARA in accordance with 36 CFR 1230.

e. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to John J. Pershing VA Medical Center s control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

f. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and John J. Pershing VA Medical Center s guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

g. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with John J. Pershing VA Medical Center s policy.

h. The Contractor shall not create or maintain any records containing any non-public John J. Pershing VA Medical Center s information that are not specifically tied to or authorized by the contract.

i. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

j. The John J. Pershing VA Medical Center owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which John J. Pershing VA Medical Center shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

k. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

4. FLOWDOWN OF REQUIREMENTS TO SUBCONTRACTORS

a. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract, and require written subcontractor acknowledgment of same.

b. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.