STATEMENT OF WORK (SOW) Contract Number: (completed by the CO at time of award) Task Order Number: (completed by the CO at time of award if a TO) IFCAP Tracking Number: 646-24-1-233-0097 Follow-on to Contract and Task Order Number: (If this is a follow-on order to a previous contract or TO, insert the contract number or the TO number to which it is a follow-on. If this is not for a follow-on, state Not Applicable ) 1. Contracting Officer s Representative (COR). Name: Jason Tedrow Section: Lead Medical Technologist Address: University Drive, Pittsburgh, PA 15240 Phone Number:
+1 (555) 000-0000 Fax Number: E-Mail Address:
contact@example.gov 2. Contract Title. Bioness L300 Go Functional Electrical Stimulation System . 3. Background. The VA Pittsburgh Healthcare System (VAPHS) Medicine Department requires one (1) Brand Name or Equal to the Bioness L300 Go Functional Electrical Stimulation System for patient care. 4. Scope. Functional electrical stimulation (FES) systems are capable of assisting with noticeable improvements for patients with foot drop and/or knee instability caused by an upper motor neuron disease or injury from such conditions as Stroke, Multiple Sclerosis, Cerebral Palsy, Traumatic Brain Injury, or Incomplete Spinal Cord Injury. The FES promotes recovery by activating the neuromuscular pathways required for gait. The vendor will supply the requested L300 Go system and provide training and support. 5. Specific Tasks. We are requesting one (1) Brand Name or Equal to the Bioness L300 Go Functional Electrical Stimulation System Specific criteria for the monitor must meet: Must be a Functional Electrical Stimulation (FES) system with External Pulse Generators (EPG) Must have EPGs for right and left thighs, right and left lower legs, and foot sensor Sensors must be mounted on adjustable straps Sensors must be able to be charged for wireless use System must be able to measure the gait of the patient Cuffs must be able to be cleaned with 70% ethanol Control unit must be able to be cleaned with 70% isopropyl alcohol Vendor must provide training and support 6. Place of Performance. Government site: VA Pittsburgh Healthcare System, University Dr, Pittsburgh, PA 15240 Physical Rehab 7. Period of Performance. this is a one-time equipment purchase. 8. Delivery Location. VA Pittsburgh Healthcare System University Dr Pittsburgh, PA 15240 Physical Rehab The Government and the Contractor understand and agree that the services to be delivered under this contract by the Contractor to the Government are non-personal services and the parties recognize and agree that no employer-employee or master-servant relationships exist or will exist under the contract between the Government and the Contractor s employees. GOVERNMENT FURNISHED INFORMATION OR MATERIAL: This acquisition does not include Government-furnished property (GFP), identify in the Statement of Work all available information on GFP to be provided, including the make, model, bar code number and serial number, if available, of all accountable assets with an acquisition cost of $500 or more. This acquisition does not include Contractor-acquired property (CAP). CONTRACTING OFFICER'S REPRESENTATIVE (COR): The identified COR and technical representative for this acquisition is: Government Representative Jason Tedrow Phone Number:
+1 (555) 000-0000 Government personnel, other than the Contracting Officer, have the authority to change or alter these requirements. The COR shall clarify technical points or supply relevant technical information, but no requirements in this scope of work may be altered as a sole result of such verbal clarification. Information Security The vendor will not have any access to sensitive VA information. The C&A requirements do not apply, and that a Security Accreditation Package is not required. SECURITY/NATIONAL AGENCY CHECK REQUIREMENTS: The C&A requirements do not apply, and that a Security Accreditation Package is not required. Training Any training scheduled should be coordinated with the COR and VA staff. Additional Charges There will be no additional charges with the waste management protocol listed in section 8. Influenza Vaccination VHA Directive 1192 requires all health care personnel (HCP) to participate in the seasonal influenza prevention program and outlines the key implementation steps. Health care personnel is defined in VHA Directive 1192 as all VA licensed and unlicensed, clinical, and administrative, paid, and unpaid, full- and part-time employees, intermittent employees, fee basis employees, VA contractors, students, researchers, volunteers, and trainees who work in VHA locations. HCP covered by the policy are expected to receive annual influenza vaccination. This requirement is extended to all Contractor personnel with potential to come into minimal contact (passing in the corridor) with any patients, visitors, or staff members at VA. Those individuals unable or unwilling to be vaccinated are required to wear a face mask throughout the influenza season. Masks are available at entrances throughout the medical center. It is the responsibility of the contractor to ensure that all contract staff is compliant with the requirements outlined in VHA Directive 1192. The contractor shall maintain the following documentation: - Documentation of vaccination, e.g., signed record of immunization from a health care provider or pharmacy, or a copy of medical records documenting the vaccination. - Completed Health Care Personnel Influenza Vaccination Form (Attachment B of VHA Directive 1192) if unwilling or unable to receive the vaccine. The contractor is required to submit annual certification in the form of a memorandum to the Contracting Officer s Representative (COR) that all contract staff performing services at VA facilities follows VHA Directive 1192. HIPAA Training Certificates If Contractor will be working onsite for installation and activation of equipment, all HIPAA training completion documentation must be provided to the COR listed in the awarded contract. Tobacco All VA property is tobacco free. Contractor personnel will comply with VA tobacco and smoking policies. Violations will result in a warning and possible citation. COVID-19 Related Policies Upon entering VA, per CDC and federal regulations, all personnel must wear the required PPE while on-site; at a minimum this includes a cloth mask. PPE will not be provided by VA. All individuals are required to enter through the main entrance for temperature screening. If Contractor s temperature exceeds the designated threshold, they will be asked to leave. In the event of an FSE being forced to vacate the premises, they shall notify the necessary Rehab department staff and provide a contact for a replacement.
