27 52 23 Attachement.pdf

VACO’s OSP, ONNS, NCS 07A2, FCC Part 15 Related Devices and System MOU 09/2020

Department of Veterans Affairs

Memorandum

Date: (Current Date) (Note - UPDATE ‘BLUE’ HIGHLIGHTED ITEMS’)

From: Department of Veterans Affairs

Office of Security and Preparedness (OSP-07)

Operations and National Security Services (ONSS-07A2)

National Communications (NCS-07A2)

810 Vermont Avenue, NW (Room B47)

Washington, DC 20420

Subj: Memorandum of Understanding (MOU) for the Limited Use of Federal Communications

Commission (FCC), Part 15 related Radio, Wireless and Wireless Fidelity (WI-FI) Equipment, Systems, Operations and Functions in VA Facilities.

To: Director (00)

(Facility Name)

(Facility Street Address) (Facility City, State Zip Code Address)

1. Instructions contained herein, and FCC Risk Mitigation MOU, will assist users of the items described in providing required information to obtain VACO Authorization and Guidance in the approved use of Radio / Wireless equipment / system specified Radio Frequency (RF) Spectrums that knowingly will not cause violations of Safety of Life, Critical, Emergency, Safety and

Disaster Recovery functions and operations resulting in injuries to VA’s Patients, Public and

Employees; plus, avoiding VA Investigation and Litigation.

2. The following circumstances are the minimum required for the conditional use of Un or Non-

Licensed Radio and Wireless Equipment / System(s) and Operations in VA Owned or Leased

Facilities (here-in-after referred to as the Facility). VA Headquarters OSP-07 / OI&T MEMO

(09-29-2015), Decision Document, Realignment of Spectrum Management and Communica-tions Security (SMCS) Services from the OI&T to OSP 07, (VAIQ#76 18658), Paragraph 5, is the Authority Having Jurisdiction (AHJ) for these items confirmed by the Secretary.

3. Each item of radio and wireless equipment, system(s) or operation whose radio frequency (RF) equipment is listed under the Federal Government’s Consolidated Federal Regulations (CFR), Title 47– FCC, Communications Act of 1934 (as amended); Part 15–Radio Frequency Devices, Annex A–General, Paragraph 15.5–Technical Requirements must be installed and operated in a manner consistent with Part 15’s “Harmful Interference” and “Safety of Life” restrictions.

a. The instructions and information are expanded in CFR 47, Title 15– Department of

Commerce, under the Information Technology Management Reform Act (Public Law 104 –

106), National Telecommunications Information Administration (NTIA) Manual of

Regulations and Procedures for Federal Radio Frequency Management (aka ‘The Red

Book’), Chapter 7–Authorized Frequency Usage, Paragraphs:

1) 7.8–Purchase and Use of Non-Licensed Devices, VACO’s OSP, ONNS, NCS 07A2, FCC Part-15 Related Devices and Systems MOU 04/2020

2) 7.9–Development and Use of Non-Licensed Devices, and

3) Annex K–Technical Standards for Federal Non-Licensed Devices.

b. RF devices that are FCC Part 15 and like NTIA listed shall not be installed, be a part of; or, used in VA areas where: Safety of Life; Critical; Emergency; Patient, Staff and Public

Safety and Disaster Recovery functions / operations are accomplished; OR, where “Code

Blue” (aka Cardiac Arrest / Alert) / Critical Enunciation(s); Hostile Personal or Physical

Offensives may occur (Note: a list of the minimum VA Facility Areas / Locations affected by this statement is provided as Attachment One (Note – these may be expanded by the

Facility Chief of Police and/or Ground Safety Services, with the approval of the Facility

Director in consort with our office, to suite each specific installation).

c. When FCC Part 15 or like NTIA Listed radio or wireless equipment, system or operation(s) in question exhibits external or internal interference, and cannot be corrected, they must be turned off until corrections; and/or, substitutions can be made (Contact VA’s AHJ NCS –

07A2, (202) 461-5311, (202) 461-5301 or http://vaww.netops.oit.va.gov/Frequency.asp for assistance concerning this issue).

4. Each FCC Part 15 and like NTIA listed Radio and Wireless Equipment and System(s):

a. That is allowed, by OI&T, to connect to an OI&T Network, shall conform to one of the

Department of Commerce’s approved National Recognized Testing Labatory’s (i.e. NRTL -

Underwriters Laboratories, Inc. [UL], etc) UL 60950-1/2, IT Equipment – Safety, General

Requirements; Federal Information Processing Standards (FIPS) 140-2, Security Requirements for Cryptographic Modules AND the appropriate UL / FIPS listing sticker/label must be permanently attached to each equipment item. A list of the minimum equipment and systems affected by this statement is provided in Attachment Two.

b. Must be installed as a ‘stand alone’ frequency restricting / isolating system (i.e. 802.11[*] type distribution system, etc.). Direct connection to the patient shall not be allowed (re UL

60950-1/2, Paragraph 1.1.2).

1) The Facility’s Bio-Medical Engineering Service must review each equipment item and system to insure it is not installed or operated in “Safety of Life” location(s) and survey each item and system initially, and on-going (a minimum of once every six months) for its service life, to insure interference is not being generated with or being interfered by other equipment or system.

2) The Facility Safety Officer shall insure that appropriate and extensive HIPAA and PII training is provided for users of FCC Part 15 and NTIA listed RF equipment and systems that may be approved for use in VA / Facility uses; and provide copies of training completion to SMCS 07A2 for filing in their permanent Station File.

5. The use of FCC Part 15 and like NTIA listed radio and wireless equipment and systems in the remaining parts of the Facility may be conditionally approved, on a case-by-case basis, with consensus of the below identified Region, VISN and Facility Authoritative Individuals; and our office after VA’s Risk Assessment and Mitigation Document is accomplish for each of the aforementioned equipment and system; and, made an official attachment to this MOU (Note:

copy(s) of these documents are available form VA’s AHJ, SMCS 07A2 at the telephone number(s) and address mentioned herein).

6. FCC Part 15 and like NTIA listed radio and wireless equipment’s RF band(s) of operation are not owned, managed or controlled by VA; but by others (i.e. Nurses Call UL-1069, Edition 7, Paragraph 2.1.2–provides this definition “wireless devices that utilize a ‘shared’ radio (ie RF) space that is not guaranteed to be available or work in all real world environments”).

Therefore, great care must be taken to insure that when any system and equipment identified herein is anticipated to be used; a complete safety evaluation and cost benefit analysis (CBA) are accomplished to insure the use of Medical Care / Tax Payer Funds would be a reasonable investment since the possibility exists VA’s AHJ, NCSS 07A2 may require the Facility to turn it off in the future.

7. A fully accomplished copy of this Non-Licensed Wireless Use MOU; indicating full vetting and approval, must be provided to our office FOR EACH FCC Part 15 and like NTIA Listed Radio and Wireless Equipment and System that is installed and used in and by the Facility.

8. OI&T Data Transmission Safety / Security (FIPS 140-2) Certification requirement(s) may be obtained from VA’s OCIS – 005OP2 at (304) 262-7757.

9. Connecting any RF System to a Nurses Call / Code Blue System: each connection must conform to the following Occupational Safety and Health Administration (OSHA), Assistant

Secretary Extracts provided for your informational purposed (Note - complete copies of these documents are provided in Attachment Three).

“a. Nurse call systems are tested against the provisions of Nationally Recognized Testing

Laboratory NRTL (UL) Standard 1069 Hospital Signaling and Nurse Call Equipment, Revision 7, or its equivalent. This testing is the minimum basis for certification and/or approval by a NRTL. Such a certification and/or approval is what OSHA requires. Pocket paging (aka RF) systems are normally only tested for fire and electrical shock producing hazards and are not tested as extensively as a Nurse Call/Code system which is also tested for reliability of operation and performance.

b. If a nurse call system is interfaced with a pocket paging (aka RF) system, each whole system

(the nurse call system plus the pocket paging [RF] system) must be tested against the provisions of UL 1069 or its equivalent. Otherwise the NRTL certification and / or approval is not valid and it will not meet OSHA requirements.”

c. VA applies this OSHA decision to all VA emergency and safety systems where an RF attachment may be anticipated requiring the execution of this MOU.

10. An additional area of concern – VA (VHA) has executed a MOU concerning the design, use, installation and operation of Radio Frequency Tracking and Locating System (RFLS) system(s) within their facilities, that must be a part of each Facility’s Radio System Official Documents with concurrent copies provided to NCS 07A2 (a copy is provided in Attachment Four).

11. One final note - the use of Wireless Fidelity (Wi-Fi) based equipment and systems ARE

NOT ALLOWED for connection to, or be a part of, Code Blue and Nurses Call, Emergency, Critical, Life and Public Safety (i.e. Distributed (in house) Radio Responder

Antenna System), Emergency, Safety, Disaster Recovery and other like operations and functions.

Donald Bronson, VACO, Chief, NCS (07A2) ____________________, Facility, Director (00)

Date: ________________________________ Date: _________________________________

(Note: Required additional minimum concurrences follows next page)

Additional, minimum required concurrence for accomplishing VACO OSP, ONNS, NCS 07A2, FCC Unlicensed RF Devices MOU:

Facility Management Officer (XXX) Facility Engineering Officer (XXX)

Date: ___________________________ Date: _________________________

Facility / Network CIO Officer (XXX) Facility Safety Officer (XXX)

Date: ___________________________ Date: __________________________

Network ______, Director (XX) Region _____, Director (XX)

Date: ___________________________ Date: __________________________

(Additional concurrence if necessary)

Date: ___________________________ Date: __________________________

Date: ___________________________ Date: __________________________

Attachments (Four)

ATTACHMENT ONE

FCC Part 15 & NTIA SAFETY OF LIFE LOCATIONS

1. The following areas are considered the minimum Facility (VAMC owned or Leased) “Safety of Life” locations affected by this MOU for the restricted use and installation of FCC Part 15 and NTIA listed items until VA, respective OEM(s) and NTIA can find a suitable RF and OI&T obtains OSHA, VHA

CEOSH and OSP, NCS 07A2 NFPA 101 Life Safety Code and NRTL UL 1069-Edition 7 Standard for Hospital Signaling Code Certifications, Listing and Approvals that can be used throughout the following minimum VA Medical Care Facility locations:

a. Surgery:

(1) Medical,

(2) Dental,

(3) Day, and

(4) Other designated Patient Care and Day Surgery Locations ( ).

(If none – add “NA”).

b. Medical Recovery:

(1) Medical,

(2) Surgical,

(3) Dental, and

(4) Other designated Patient Care Locations ( ).

(If none – add “NA”).

c. Treatment / Care Rooms:

(1) Emergency,

(2) Triage,

(3) Intensive Care Units (ICU):

(a) Spinal Cord,

(b) Medical,

(c) Surgical,

(d) Cardiac Care (CCU).

(4) Designated Step Down Areas ( ).

(If none, add “NA”), and

(5) Other designated Patient Care Locations ( ).

(If none – add “NA”).

d. Procedure Rooms:

(1) Dialysis,

(2) Oncology,

(3) Radiology,

(4) MRI (if not a part of Radiology),

(5) Physical Therapy, and

(6) Other designated Patient Care Locations ( ).

(If none – add “NA”).

e. Other location(s) where “Day Surgery” may be accomplished.

2. Limited Response Areas, certain designated:

a. Parking locations,

b. Stairwell locations,

c. Facility / Grounds Entrance / Exit locations,

d. Facility Full Interstitial locations,

e. Other designated Facility Locations ( ), and

(If none – add “NA”).

3. Other Designated Facility Location(s):

a. As approved during the Project / Contract Design Stages ________ .

(Place N/A if additions are not required)

ATTACHMENT TWO

FCC PART 15 & NTIA LISTED EQUIPMENT/ SYSTEMS

1. The following Devices / Items are considered the minimum Facility “Safety of Life” Equipment /

Systems affected by this MOU for the restricted use and installation of FCC Part 15 listed items until

VA, respective OEM(s) and NTIA can find a suitable Government Protected Band of RFs that can be used throughout the Facility:

a. Code Blue (also Nurses Call System if Code Blue is an integral part of the system):

(1) Radio Pagers,

(2) Pocket Pagers,

(3) Other wireless instruments, and

(4) All Wireless Fidelity (WI-FI) equipment and system(s) not allowed.

b. Emergency Voice Switching (i.e. Analog/Digital Telephone):

(1) Telephone Private Branch Exchange (PBX) Room (TER),

(2) Telephone Operators Room (TOR)

(3) Telephone Wireless Sets,

(4) Answering Machines, and

(5) Copying Machines.

c. VoIP - if used as a voice / telephone substitute since VA’s VoIP is not Nationally Listed, Labeled or Coded for Critical Service, Life and Public Safety and Emergency functions.

d. LAN/WAN (unless it is Life Safety Coded Listed, contains OSHA, VHA CEOSH and VA’s Low

Voltage Communications AHJ (NCS 07A2) current certifications and approvals):

(1) Wireless Laptops,

(2) Wireless Data / LAN / WAN Equipment,

(3) Other Wireless Equipment, and

(4) Wireless Fidelity (WI-FI) not allowed,

e. Public Address cannot be a part of, connected to or controlled by the VoIP system (unless the

VoIP is OSHA, NFPA 101 Life Safety Code & NRTL UL 1069 Listed, Labeled and has VHA

CEOSH & NCS 07A2 approvals).

f. Radio Base Stations, Repeaters be a part of, connected or controlled by the VoIP system (unless the VoIP is OSHA, NFPA 101 Life Safety Code & NRTL UL 1069 Listed, Labeled and has VHA

CEOSH & NCS 07A2 approvals).

g. Police Service Security Management System providing Patient, Public and Staff Safety, Emergency, Critical and Disaster Recovery Functions, Operations and Directions:

1) Parking Lot “Code Blue” Emergency Voice Communications Units,

2) Parking Deck “Code Blue Emergency Voice Communications Stations,

3) Duress Emergency Alarm Stations / Locations,

4) Elevator Cab Emergency Voice (aka Fireman’s) Phones,

5) Facility wide Emergency (aka Crash) Phone functions, and

6) Other Emergency Voice (aka Phone)/System Notifications.

2. Other Designated Facility Safety / Emergency Equipment / System(s): ___________

(Place “N/A” if not required)

ATTACHMENT THREE

FCC PART 15 POCKET PAGING (RF) & ANCILLARY (ADD-ON) EQUIPMENT

OSHA AND NRTL

OFFICIAL OSHA DETERMINATIONS

“December 29, 1989 (NCS 07A2, reaffirmed 2020)

Mr. Thomas J. Frericks, Jr.

President/General Manager

Copp Systems, Inc.

123 South Keowee Street

Dayton, Ohio 45402

Dear Mr. Frericks:

This is in response to your letter of September 8, addressed to former Acting Assistant Secretary Alan C.

McMillan, concerning nurse call systems. We regret the delay you have experienced in receiving our reply.

In order to respond more adequately to the question raised in your letter, we contacted the Underwriters

Laboratories, Inc. (UL) and discussed nurse call systems. Their explanation and the Occupational Safety and Health Administration (OSHA) requirements are as follows:

Nurse call systems are tested against the provisions of UL Standard 1069, Hospital Signaling and Nurse

Call Equipment, or its equivalent. This testing is the basis for certification and/or approval by a Nationally

Recognized Testing Laboratory (NRTL). Such a certification and/or approval is what OSHA requires.

Pocket paging systems are normally only tested for fire and electrical shock producing hazards and are not tested as extensively as a nurse call system which is also tested for reliability of operation and performance.

If a nurse call system interfaces with a pocket paging system, each whole system (the nurse call system plus the pocket paging system) must be tested against the provisions of UL 1069 or its equivalent. Otherwise the NRTL certification and/or approval are not valid and it will not meet

OSHA requirements.

Special electrical equipment, such as the nurse call system, is acceptable to the Assistant Secretary of Labor, and approved within the meaning of Subpart S of the OSHA General Industry Standards

29 CFR 1910, if it is accepted, or listed, or labeled, or otherwise determined to be safe by a NRTL.

Alan C. McMillan

Assistant Secretary

Occupational Safety and Health”

“September 12, 1991 (NCS 07A2, reaffirmed 2020)

Mr. Kenneth T. James

Chairman, Hospital Signaling Group

National Electrical Manufacturers Association (NEMA), Suite 300

2101 L Street, N.W.

Washington, D.C. 20210

Dear Mr. James:

Thank you for your inquiries of June 26, and August 14, pertaining to electrical interface units used to connect nurse call systems with pocket page transmitters and other ancillary equipment. We apologize for the delay in responding.

In your letter you asked us to reconsider a statement from our April 23 response to you, as follows:

"Because it is not clear that an approved interface would eliminate errant current potentially introduced by pocket page transmitters connected to the interface, OSHA cannot accept such a hookup, unless the entire system is approved through testing under UL 1069 or its equivalent." At the time of our April 23 letter, we did not have definitive input from the Underwriter Laboratories advising that the UL 1069 approval of the interfaces included evaluation for the safe handling of errant electrical current by the interfaces. The letter of June 17 from Mr. P. E. Patty and Mr. I. I. Papier of Underwriters Laboratories Inc. (UL) to this office (copy enclosed) has provided the necessary input for us to answer your concern. The last paragraph on page one and the first paragraph on page two of that letter cover the issue. They are quoted as follows:

“The interface serves to isolate and safeguard the functionality of the nurse call system. Under the new requirements, which become effective on March 1, 1992, the interface function requirements will be expanded to include leakage current affecting the patient which is a magnitude significantly smaller than the safety levels for hospital workers.”

We are in the process of conducting a file review on all presently listed products to determine their compliance with a revised UL 1069 which goes into effect March 31, 1992. The revised Standard addresses your concern about leakage currents that may enter a nurse call system through an interface as a result of the operation of ancillary type equipment. Specifically, Par.4.2 of UL 1069 states:

“isolation shall be provided between any equipment, such as CRTs, printers, pocket page, telephone and the like, and circuits extending into the patient care area stations so that, in the event of breakdown between primary and secondary windings, the high voltage does not appear on the patient circuits and the sum of the leakage currents from the nurse call system and ancillary equipment does not exceed the limits of the Leakage Current Test as described in this Standard.”

In light of the above communication, interface units determined by Underwriters Laboratories to be in compliance with the new UL 1069 requirements which will go into effect on March 1, 1992, will be acceptable under 29 CFR 1910.303(a). Pocket page transmitters and other ancillary equipment connected to acceptable interface units must also have been determined to be safe, independently or in combination with the interface unit, by a nationally recognized testing laboratory (ie UL, CSA, etc.).

If we can provide further assistance, please do not hesitate to contact us again.

Sincerely, Patricia K. Clark, Director

Directorate of Compliance Programs”

“May 11, 2004 (NCS 07A2, reaffirmed 2020)

Mr. Mark Pendlebury, President

Penmar Automation, Inc.

1151 Gorham Street, Unit 18

Newmarket, Ontario, Canada L3Y 7V1

Dear Mr. Pendlebury:

Thank you for your January 6, 2004 letter to the Occupational Safety and Health Administration's

(OSHA's) Directorate of Enforcement Programs (DEP). This letter constitutes OSHA's interpretation only of the requirements discussed and may not be applicable to any questions not delineated within your original correspondence. You are requesting a comparison analysis concerning the harmonization of the

Canadian Standards Association (CSA) Z142-02 code with the 29 CFR 1910.212 and 1910.217 standards.

On January 22, 2004, Willie Robinson of my staff and Bernard Pasquet (Directorate of Science, Technology and Medicine) contacted you by telephone to better understand your request. At that time, we explained that OSHA does not perform comparison analyses of its standards with Canadian or other standards. However, you clarified that you merely wanted to know the OSHA requirements applicable to the equipment you want to sell in the United States (US). You indicated that this equipment was an electrical control panel or set of electrical controls for a certain kind of industrial machine.

Based on the facts in the above paragraph, it appears your control equipment would meet our definition of electrical equipment. As such, please be advised that electrical equipment must be approved by a

Nationally Recognized Testing Laboratory (NRTL) in accordance with the OSHA requirement at

29 CFR 1910.303(a). In addition, NRTLs must approve this equipment using US recognized test standards, based on requirements under 29 CFR 1910.7. As a result, electrical equipment required to be NRTL approved and used in the US and its territories must conform to US recognized test standards. Moreover, an employer must install and use electrical equipment in accordance with instructions included in the listing and labeling provided by the particular NRTL, as required under

1910.303(b).

Considering your clarification, these are the OSHA requirements applicable to the equipment you described. However, please note that employers also may be subject to other requirements applicable to electrical equipment depending on the specific circumstances of its use or installation.

You indicated that your controls have been approved by CSA, an OSHA recognized NRTL, but the approval was done using the Canadian test standard. Mr. Pasquet indicated that he believed the US test standard applicable to your equipment, and which we have approved NRTLs to use, is Underwriters

Laboratories (UL) 508 Industrial Control Equipment. You should contact UL if you are interested in any comparison of UL 508 to a comparable Canadian standard. This action would not require any intervention by OSHA. Please note that UL, CSA, or any other NRTL that is approved to use UL 508 may determine whether your equipment conforms to that standard and thus approved for use in the US and its territories.

Thank you for your interest in occupational safety and health. We hope you find this information helpful.

OSHA requirements are set by statute, standards, and regulations. Our interpretation letters explain these requirements and how they apply to particular circumstances, but they cannot create additional employer obligations. This letter constitutes OSHA's interpretation of the requirements discussed. Note that our enforcement guidance may be affected by changes to OSHA rules. Also, from time to time we update our guidance in response to new information.

To keep apprised of such developments, you can consult OSHA's website at http://www.osha.gov. If you have any further questions, please feel free to contact the Office of General Industry Enforcement at (202)

693-1850.

Sincerely, Fairfax, Director

Directorate of Enforcement Programs

[Corrected October 11, 2012]”

NO ADDITIONAL OSHA EXTRACTED INFORMATION FOLLOWS

ATTACHMENT FOUR

VHA AND FEDERATION OF GOVERNMENT EMPLOYIES UNION (AFGE) MOU FOR THE

MINIMUM USE OF

RTLS EQUIMENT / SYSTEMS