15.EXHIBIT 3- 36C25625Q0722 SAFETY CHECKLIST.pdf
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- Solicitation number
- 36C25625Q0722
About this file
Exhibit 3 is a Safety Checklist form used for Durable Medical Equipment (DME) and Home Medical Equipment (HME) for veteran patients. The checklist covers safety and infection control aspects, with checkboxes for verifying equipment operation, electrical safety, and cleaning techniques. The form requires checking six safety-related items, including manufacturer guidelines compliance, electrical outlet safety, grounded adapters, electrical leakage, and reporting of any unsafe conditions. An additional section focuses on infection control, specifically whether the veteran or caregiver understands cleaning techniques for the provided equipment.
The checklist is part of the 36C25625Q0722 solicitation for DME and HME services at the Michael E. DeBakey VA Medical Center in Houston, Texas. This is a small business set-aside solicitation for a five-year Indefinite Delivery Contract with a firm-fixed price. The quote submission deadline is 11:59 PM Central Standard Time on April 25, 2025, with quotes to be emailed to the Contract Specialist Jeneice Matthews. The government will award the contract using a lowest-price technically acceptable evaluation method, with requirements including current SAM registration and SBA small business certification.
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EXHIBIT 3 – SAFETY CHECKLIST
VETERAN PATIENT NAME:
SAFETY CHECKLIST: YES NO NA
1. Was equipment operating in accordance with the ( ) ( ) ( ) manufacturer’s guidelines?
2. Were the electrical outlets to be used with the equipment ( ) ( ) ( ) checked for safety?
3. Was a three (3) prong grounded adapter provided/installed? ( ) ( ) ( )
4. Was the equipment properly checked for electrical leakage? ( ) ( ) ( )
5. Were unsafe conditions discovered/identified? ( ) ( ) ( )
6. Were unsafe conditions reported to the VA/Prosthetics? ( ) ( ) ( )
INFECTION CONTROL:
1. Does the veteran/caregiver know the cleaning techniques to ( ) ( ) ( ) be used for the equipment provided?
COMMENTS: Any additional instructions reviewed with Veteran patient/caregiver:
VETERAN PATIENT/CAREGIVER SIGNATURE DATE
File details come from the government source that posted it. Updated .