Appendix A - Sample Forms.pdf

Appendix A

Sample Forms

Above Ceiling Work Permit

Confined Space Permit

Daily Construction Log

Hot work Permit

Infection Control Risk Assessment (ICRA) Permit

Permit Exempt Confined Space Entry

Request for Information (RFI) Form

Submittal form

Utility Shutdown Request Form

ATTACHMENT A ABOVE-THE-CEILING WORK PERMIT

Building:___________ Floor: ______ Room #: ______ Fire / Smoke Barrier: YES NO (circle one)

Work Coordinator/Supervisor: Name:

Phone # or Extension:

Date(s) Planned for Proposed Work:

Date Permit Submitted:

Yes No

Will the proposed work open or penetrate an existing building structural element, such as a wall or floor, which is smoke-tight or fire-rated?

If YES, complete ILSM if the penetration will not be immediately closed to describe the planned installation to restore the wall or floor to its original smoke-tight or fire-rated condition and then go to #2.

If NO, complete bottom section, numbers 3 through 6 (no approval required)

Will the opening(s) or penetration(s) created by the proposed work be sealed using a UL-approved system? Describe the planned method and attach installation detail sketch.

Fire stop system utilized, list type (must provide documentation proving fire stopping is compatible with other fire stopping in area):

Approved by: Date:

NOTE: - Contact the POC when work is complete or for additional information and assistance.

To be completed by the COR or designated staff:

Yes No

1. The proposed work area has been inspected and the proposed plan is approved.

2. A copy of the approved permit has been provided to the work coordinator/supervisor.

3. Work is complete and every opening, penetration and joint is properly sealed to prevent the escape of fire and smoke.

4. Work is complete and all acoustical ceiling tiles have been replaced.

5. All work has been completed in accordance with industry practice and applicable building fire code requirements.

6. All j-boxes in the area are closed.

Closed by: Date:

PERMIT REQUIRED CONFINED SPACE PERMIT

PART I To Be Completed by Supervisor, Facilities Management Program

1. DATE OF PLANNED ENTRY__________________________________________________

2. ESTIMATED TIME SPACE IS TO BE OCCUPIED (Hrs) ________________________

3. LOCATION OF THE PERMIT SPACE__________________________________________

4. DESCRIPTION OF WORK TO BE PERFORED IN THE PERMIT SPACE

5. DESCRIPTION OF HAZARDS: _______________________________________________

6. ISOLATION CHECKLIST: (Attach copy of each completed Lockout procedure)

Electrical Isolation________________________________________________________

Mechanical Isolation______________________________________________________

Isolation of Water or Steam________________________________________________

Other Isolation___________________________________________________________

7. HOT-WORK PERMIT REQUIRED? ___________________________________

8. ENVIRONMENTAL CONDITIONS THAT MUST BE MAINTAINED DURING ENTRY

THIS ENTRY PERMIT IS VALID ONLY

FROM: Date _____________ Time ____________ TO: Date _____________ Time ___________

Name of Supervisor (Print/Type) Date

Signature

PART II To Be Completed by Contractor’s Entry Supervisor

1. LIST THE FOLLOWING NAMES OF PERSONS:

ENTRANTS ATTENDANTS

2. TYPE OF VENTILATION TO BE USED_____________________________________________

3. DESCRIPTION OF CONTROLS REQUIRED TO ENSURE HAZARDS AND ENVIRONMENTAL

CONDITIONS IDENTIFIED IN PART I ARE MAINTAINED AT ALL TIMES DURING ENTRY

4. DESCRIPTION OF PHYSICAL BARRIERS TO PREVENT UNAUTHORIZED ENTRY INTO

SPACE

5. MEANS OF COMMUNICATION BETWEEN ENTRANTS AND ATTNDANTS

6. PERSONAL PROTECTIVE EQUIPMENT TO BE USED

Protective Clothing: _________________________________________________________________

Head, Hand, or Foot Protection: ______________________________________________________

Hearing or Eye Protection: ___________________________________________________________

Respiratory Protection: ______________________________________________________________

Other Protection: ____________________________________________________________________

7. NAME OF RESCUE SERVICE PERSONNEL

8. RESCUE EQUIPMENT TO BE USED

9. FREQUENCY OF PERIODIC ATMOSPHERIC TESTING

(If continuous air monitoring equipment is not used) ________________________

10. RESULTS OF ATMOSPHERIC TESTING:

* Initial Pre-Entry Air Test Result: (Record Time of Testing)

Date Time CO H2S O LEL (lower explosive limit)

* Required for Safety approval of Permit. (See next page for recording additional re-entry test results)

SAFE LEVELS: Oxygen between 19.5% – 23.5%: CO < 35 ppm: H2S 10 ppm: LEL < 10%

Name Contractor’s Entry Supervisor: ________________________________________________ (Print or Typed)

Signature of Contractor’s Entry Supervisor: __________________________________________

Date: __________________________________ Time: _________________________________

PART III To Be Completed by the Safety Manager (or designee)

SAFETY OFFICE APPROVAL OF PERMIT ENTRY

I have reviewed the above with the Contractor’s Entry Supervisor and found all controls required for this permit to be in place. I have informed the Contractor’s Entry Supervisor that all controls required by this permit are to remain in place for duration of occupancy of the space, and have provided the Contractor’s Entry Supervisor with Medical Center emergency contact information.

Name of Safety Manager (or designee) Signature of Safety Manager (or designee)

Date: __________________________________ Time: _________________________________

NOTE: This permit is to be posted at entrance of space prior to entry, and shall remain posted until occupancy of space is completed.

Comments:

Complete Date and Time:

Location of Work:

HOT WORK PERMIT

THIS PERMIT IS REQUIRED FOR ANY TEMPORARY OPERATION INVOLVING OPEN FLAMES, HEAT, OR

SPARKS; SUCH AS" BRAZING, CUTTING, GRINDING OR WELDING (ANY TORCH USE).

INFORMATION

Safety personnel signing this permit must have valid 30 hour OSHA card and has verified, by his/her signature that all requirements located have been verified and completed.

REQUIRED PRECAUTIONS CHECKLIST

Available sprinklers, hose streams and

COR Final Check Name and Signature: Date:

Complete Date and Time:

Supervisor Name:

Supervisor's Signature:

Hot Work Technician VA Employee/Contractor Name:

Type of Hot Work to be Performed:

Start Date and Time:

Complete Date and Time:

HOT WORK PERMIT

THIS PERMIT IS REQUIRED FOR ANY TEMPORARY OPERATION INVOLVING OPEN FLAMES, HEAT, OR

SPARKS; SUCH AS" BRAZING, CUTTING, GRINDING OR WELDING (ANY TORCH USE).

INFORMATION REQUIRED PRECAUTIONS CHECKLIST

Available sprinklers, hose streams and extinguishers extinguishers are in service/operable? Safety personnel signing this permit must have valid 30 hour OSHA card and has verified, by his/her signature that all requirements located are in service/operable?

Hot work equipment inspected and in good repair?

Requirements within 35 ft. of work

Combustable floors wet down, covered with damp have been verified and completed.

Hot work equipment inspected and in good repair?

Hot Work Technician VA Employee/Contractor Name:

Requirements within 35 ft. of work

Combustable floors wet down, covered with damp sand or fire resistive sheets

Remove other combustables or cover with fire sand or fire resistive sheets

Remove other combustables or cover with fire blankets or curtains blankets or curtains

Wall and floor openings covered

Protect or shut down ducts that may carry sparks to Protect or shut down ducts that may carry sparks to

Location of Work: Wall and floor openings covered Work on walls, ceilings, or roofs combustable areas combustable areas

Type of Hot Work to be Performed: Work on walls, ceilings, or roofs

Construction is non-combustable Construction is non-combustable Combustables have been moved away

Work in enclosed equipment Enclosed permit quipment cleaned of all

Supervisor Name:

Supervisor's Signature:

Combustables have been moved away

Work in enclosed equipment Enclosed permit quipment cleaned of all combustables Containers purged of flammable liquids or vapors Start Date and Time: Containers purged of flammable liquids or vapors combustables Pressurized vessels/piping: isolated or vented Pressurized vessels/piping: isolated or vented Fire watch/monitoring of hot work area Complete Date and Time: Fire watch/monitoring of hot work area Fire watch shall be providedf 30 minutes after work Fire watch shall be providedf 30 minutes after work Fire watch shall be provided with extinguisher(s)

Fire watch is trained in the use of extinguishers and

Complete Date and Time: Fire watch shall be provided with extinguisher(s)

Fire watch is trained in the use of extinguishers and sounding alarm Fire watch may be required in adjoining areas to sounding alarm Complete Date and Time: Fire watch may be required in adjoining areas to Monitor hot work area for three hours after job is work work

Monitor hot work area for three hours after job is Safety Final Check and Approval Name and Signature: Date:

complete complete

Comments:

COR Final Check Name and Signature: Date:

Safety Final Check and Approval Name and Signature: Date:

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. Jbartley@ameritech.net Updated, 2009.

Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation

Step One:

Using the following table, identify the Type of Construction Project Activity (Type A-D)

TYPE A

Inspection and Non-Invasive Activities.

Includes, but is not limited to:

• removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet

• painting (but not sanding)

• wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

TYPE B

Small scale, short duration activities which create minimal dust Includes, but is not limited to:

• installation of telephone and computer cabling

• access to chase spaces

• cutting of walls or ceiling where dust migration can be controlled.

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies Includes, but is not limited to:

• sanding of walls for painting or wall covering

• removal of floorcoverings, ceiling tiles and casework

• new wall construction

• minor duct work or electrical work above ceilings

• major cabling activities

• any activity which cannot be completed within a single workshift.

TYPE D

Major demolition and construction projects Includes, but is not limited to:

• activities which require consecutive work shifts

• requires heavy demolition or removal of a complete cabling system

• new construction.

Step 1:

mailto:Jbartley@ameritech.net

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. Jbartley@ameritech.net Updated, 2009.

Step Two:

Using the following table, identify the Patient Risk Groups that will be affected.

If more than one risk group will be affected, select the higher risk group:

Low Risk Medium Risk High Risk Highest Risk

• Office areas

• Cardiology

• Echocardiography

• Endoscopy

• Nuclear Medicine

• Physical Therapy

• Radiology/MRI

• Respiratory

Therapy

• CCU

• Emergency Room

• Labor & Delivery

• Laboratories

(specimen)

• Medical Units

• Newborn Nursery

• Outpatient Surgery

• Pediatrics

• Pharmacy

• Post Anesthesia Care

Unit

• Surgical Units

• Any area caring for immunocompromised patients

• Burn Unit

• Cardiac Cath Lab

• Central Sterile Supply

• Intensive Care Units

• Negative pressure isolation rooms

• Oncology

• Operating rooms including C-section rooms

Step 2 Step Three: Match the

Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D) on the following matrix, to find the … Class of Precautions (I, II, III or IV) or level of infection control activities required.

Class I-IV or Color-Coded Precautions are delineated on the following page.

IC Matrix - Class of Precautions: Construction Project by Patient Risk

Construction Project Type

Patient Risk Group TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV Note: Infection Control approval will be required when the Construction Activity and Risk Level indicate that Class III or Class IV control procedures are necessary.

Step 3

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. Jbartley@ameritech.net Updated, 2009.

Description of Required Infection Control Precautions by Class During Construction Project Upon Completion of Project

C L

A

SS

I 1. Execute work by methods to minimize raising dust from construction operations.

2. Immediately replace a ceiling tile displaced for visual inspection

1. Clean work area upon completion of task.

A

SS

II

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area

6. Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with cleaner/disinfectant.

2. Contain construction waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Upon completion, restore HVAC system where work was performed.

A

SS

II

I

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

2. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion, restore HVAC system

A

SS

IV

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Dept.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Contain construction waste before transport in tightly covered containers.

4. Cover transport receptacles or carts. Tape covering unless solid lid.

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion, restore HVAC system

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. Jbartley@ameritech.net Updated, 2009.

Step 4. Identify the areas surrounding the project area, assessing potential impact

Unit Below Unit Above Lateral Lateral Behind Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Step 5. Identify specific site of activity e.g., patient rooms, medication room, etc.

Step 6. Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.

Step 7. Identify containment measures, using prior assessment. What types of barriers?

(E.g., solids wall barriers); Will HEPA filtration be required?

(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

Step 9. Work hours: Can or will the work be done during non-patient care hours?

Step 10. Do plans allow for adequate number of isolation/negative airflow rooms?

Step 11. Do the plans allow for the required number & type of handwashing sinks?

Step 12. Does the infection prevention & control staff agree with the minimum number of sinks for this project? (Verify against FGI Design and Construction Guidelines for types and area)

Step 13. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

Step 14. Plan to discuss the following containment issues with the project team.

E.g., traffic flow, housekeeping, debris removal (how and when), Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The ICRA may be modified throughout the project.

Revisions must be communicated to the Project Manager.

Steps 1-3 Adapted with permission V Kennedy, B Barnard, St Luke Episcopal Hospital, Houston TX; C Fine CA Steps 4-14 Adapted with permission Fairview University Medical Center Minneapolis MN Forms modified /updated; provided courtesy of Judene Bartley, ECSI Inc. Beverly Hills MI 2002. Jbartley@ameritech.net Updated, 2009.

Infection Control Construction Permit Permit No:

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work: Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity GROUP 1: Low Risk TYPE B: Small scale, short duration, moderate to high levels GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities Requiring consecutive work shifts

GROUP 4: Highest Risk

CLASS I 1. Execute work by methods to minimize raising dust from 3. Minor Demolition for Remodeling construction operations.

2. Immediately replace any ceiling tile displaced for visual inspection.

CLASS II 1. Provides active means to prevent air-borne dust from 6. Contain construction waste before transport in tightly dispersing into atmosphere covered containers.

2. Water mist work surfaces to control dust while cutting. 7. Wet mop and/or vacuum with HEPA filtered vacuum

3. Seal unused doors with duct tape. before leaving work area.

4. Block off and seal air vents. 8. Place dust mat at entrance and exit of work area.

5. Wipe surfaces with cleaner/disinfectant. 9. Isolate HVAC system in areas where work is being performed; restore when work completed.

CLASS III

1. Obtain infection control permit before construction begins. 6. Vacuum work with HEPA filtered vacuums.

2. Isolate HVAC system in area where work is being done to 7. Wet mop with cleaner/disinfectant prevent contamination of the duct system. 8. Remove barrier materials carefully to minimize

3. Complete all critical barriers or implement control cube spreading of dirt and debris associated with method before construction begins. construction.

9. Contain construction waste before transport in

4. Maintain negative air pressure within work site utilizing tightly covered containers.

HEPA equipped air filtration units. 10. Cover transport receptacles or carts. Tape covering.

5. Do not remove barriers from work area until complete 11. Upon completion, restore HVAC system where work project is checked by Infection Prevention & Control and was performed.

thoroughly cleaned by Environmental Services.

Date

Initial

CLASS IV

1. Obtain infection control permit before construction begins. 8. Do not remove barriers from work area until completed

2. Isolate HVAC system in area where work is being done to project is checked by Infection Prevention & Control prevent contamination of duct system. and thoroughly cleaned by Environmental. Services.

3. Complete all critical barriers or implement control cube 9. Vacuum work area with HEPA filtered vacuums.

method before construction begins. 10. Wet mop with disinfectant.

4. Maintain negative air pressure within work site utilizing 11. Remove barrier materials carefully to minimize

HEPA equipped air filtration units. spreading of dirt and debris associated with

5. Seal holes, pipes, conduits, and punctures appropriately. construction.

6. Construct anteroom and require all personnel to pass 12. Contain construction waste before transport in tightly through this room so they can be vacuumed using a HEPA covered containers.

vacuum cleaner before leaving work site or they can wear 13. Cover transport receptacles or carts. Tape covering.

cloth or paper coveralls that are removed each time they 14. Upon completion, restore HVAC system where work leave the work site. was performed.

7. All personnel entering work site are required to wear shoe covers

Date

Initial

Additional Requirements:

Date Initials Exceptions/Additions to this permit

Date Initials are noted by attached memoranda Permit Request By: Permit Authorized By:

Date: Date:

PERMIT EXEMPT SPACE ENTRY CERTIFICATE

(Complete All Items)

LOCATION OF SPACE: _________________________________________________________

DATE AND TIME OF ENTRY:__________________________________________

NAME OF ENTRY SUPERVISOR (Print) ________________________________________________ NOTE: An entry supervisor also may serve as an attendant or as an authorized entrant, as long as that person is trained and equipped as required by this section for each role he or she fills. Also, the duties of entry supervisor may be passed from one individual to another during the course of an entry operation.

NAME OF THE AUTHORIZED ENTRANT(S):

NAME OF ATTENDANT(S)

LOCATION OF THE EXEMPT SPACE:

DESCRIPTION OF MECHANICAL VENTILATION SYSTEM USED:

(If fan is used, fan must be OSHA certified fan for confined space)

DESCRIPTION OF PHYSICAL BARRIER(S) TO PREVENT UNAUTHORIZED ENTRY INTO

SPACE

ENERGY SOURCES LOCKED OUT (Attach copy of each completed Lockout procedure)

* Initial Pre-Entry Air Test Result: (Record Time of Testing)

Date Time CO H2S O2 LEL (lower explosive limit)

* Required to be taken prior to entry into the space.

SAFE LEVELS: Oxygen between 19.5% – 23.5%: CO < 35 ppm: H2S 10 ppm: LEL < 10%

Additional Re-Entry Air Test Results: Note: Atmospheric re-testing is required each time the space is re-entered. Use back of form is more testing is required.

Date Time CO H2S O2 LEL (lower explosive limit)

DATE AND TIME OF COMPLETION OF OCCUPANCY OF THE SPACE

SIGNATURE OF ENTRY SUPERVISOR:

NOTE: Exempt Space Entry Certificate must be returned to the Safety Office upon completion of occupancy of the space.

Edward P. Boland VA Medical Center

VA Central Western Massachusetts Healthcare System 421 North Main Street

Leeds, MA 01053-9764

REQUEST FOR INFORMATION

NO.

PROJECT TITLE:

LOCATION: JOB:

CONTRACT NO.:

VA PROJECT NO.:

DATE REQUIRED:

TO: CC:

REQUEST SUBJECT:

Requested By: Date:

Signed:

RESPONSE:

This response does not constitute a change to the contract and is not an authorization to the contractor to proceed with any work that modifies the contract price or the time of performance. If the contractor believes that this response modifies any portion of the contract, the contractor shall make timely notice to the Contracting Officer and await the Contracting Officer’s direction before proceeding with any work that the contractor believes is a modification to the contract.

This response may constitute a change to the contract documents. Do not proceed with any work indicated in this response that changes the contract documents until directed in writing by the Contracting Officer.

Response By: Concur:

Signed:

Signed:

VA Project Manager

Date: Date:

MATERIAL APPROVAL SUBMITTAL

(See Instructions on Reverse)

TO: (Contracting Officer) FROM: (Contractor) DATE

CONTRACT NUMBER SUBMISSION NUMBER SUBMITTAL

NEW RESUBMITTAL

PREVIOUS SUBMISSION NUMBER PROJECT NUMBER

TO BE COMPLETED BY CONTRACTOR FOR GOVERNMENT USE ONLY

ITEM

NO.

SPECIFICATION SECTION/

PARA NO./DRAWING NO.

DESCRIPTION OF MATERIAL

(Include Type, Model Number, Mfg., etc. & file name of attachments)

AP-

PROVED

DISAP-

PROVED

SEE

REVERSE INITIAL

BY COMPLETING THIS FORM, THE UNDERSIGNED CONTRACTOR CERTIFIES THAT

THE MATERIAL COMPLIES WITH ALL SPECIFICATIONS OF SUBJECT CONTRACT.

DATE TYPE OR PRINT NAME AND TITLE SIGNATURE

FOR GOVERNMENT USE ONLY

TO: (A/E)

For Evaluation and Action

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

TO: (VA Engineer / COR)

RECOMMEND APPROVAL DISAPPROVAL AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

TO: (Contracting)

APPROVED DISAPROVED AS INDICATED ABOVE AND SUBJECT TO ANY APPLICABLE COMMENTS ON THE REVERSE SIDE. REQUEST

RESUBMITTAL ON DISAPPROVED ITEMS WITHIN DAYS OF DATE SHOWN BELOW.

DATE TYPE OR PRINT NAME AND GRADE SIGNATURE

COMMENTS

(Number to correspond with applicable Item Number on reverse)

INSTRUCTIONS TO CONTRACTORS

1. The term "material" is defined as articles, supplies, raw materials, equipment, parts, components, and completed end items that are to be incorporated into the work required by the contract.

2. This form is to be used by Contractors for submitting Shop Drawings (*.DWG or *.PDF format), Manufacturer's Literature and Certificates (scanned as * .PDF) to the Government for approval in accordance with the provisions of this contract. Unless otherwise specified, it is to be prepared, signed, and E-mailed to the Contracting Officer with appropriate attachments. One paper format copy shall be submitted as well.

3. Item(s) to be approved will be clearly tabbed or identified. Data pertaining to item(s) to be approved will be clearly identified or tabbed, particularly where documents are voluminous, in order to properly evaluate the materials or articles to be incorporated in the work. Each attachment will be numbered to correspond with the item number shown on the face of this form.

4. Requests submitted shall be numbered consecutively, by contract, in the space entitled "Submission No.". This number, in addition to the Contract No., will be used to identify each Material Approval Submittal. Resubmissions will be indicated in the appropriate block and the insertion of previous submission number and data in addition to a new submission number. A single submission should be used for all work of a section of the specifications, but in NO instance should the submission include work for more than one (1) contract. Allow reasonable time in accordance with the project specifications for review of the submittal(s) by the A/E and Government. Submittals requiring priority handling will be submitted by separate submittal using the form and so marked across the face of the form.

5. This Material Approval Submittal is not valid unless it is signed by the Contracting Officer. This approval is required as called for by the Contracting Officer under the terms of this contract. One paper copy of the submittal is to be hand signed for Contracting Officers records.

6. The A/E and Government review is limited to checking for conformance with the information given and the design concept expressed in the contract documents. The Contractor and/or Construction Manager remains totally responsible for confirming all dimensions, quantities, fabrication, construction means and methods, techniques, sequences in the work, procedures, and coordination of the work for all trades.

7. This review does not relieve the Contractor of full responsibility for strict compliance with all requirements of contract plans and specifications. Provide and install all supplementary or miscellaneous items, appurtenances, devices and their available options incidental to or necessary for a functionally, sound, secure, complete, compatible and code compliant system.

VA CWM Utility Shutdown Request

• Major Shutdown: Provide Request a minimum of 10 Working days prior to shutdown to allow for coordination.

• Minor (low impact): Provide request a minimum of 3 working days prior to shutdown.

• To determine extent of shutdown provide panel schedules and/or drawings to COR with this request.

• Contractor is responsible for providing properly trained personnel to perform the shutdown, Lock Out/Tag

Out, deenergizing, and reenergizing.

• If work requires confined space, hot work or blocking egress coordinate with Project COR for required permits.

Date of Request:

Requested Date of Shutdown

Start Time

End Time

Shutdown Duration

Building/Location

Utility Being

Areas impacted by

PPE Required

Lock Out / Tag out Required

Notes/Comments

Have all Lock Out/Tag Out and Required PPE onsite prior to shutdown. Failure to have the proper equipment will result in the shutdown being cancelled.

Requestor Name

Requestor Signature & Date

COR comments / Special considerations for shutdown/Start-up

APPROVED DENIED

COR Name:

COR Signature & Date:

O&M Shop Acknowledged

Name & Date

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