36C25820B0010-008.pdf

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10.0%

7.5%

5.0%

ON FIRST $20,000

ON NEXT $30,000

ON BALANCE OVER $50,000

3B

1C

3A

1A

(Line 6 and 7)10.0%

INSURANCE AND TAXES

OMITTED WORK

(CREDIT)

(B)

PRIME

CONTRACTOR

FEE

OTHERS (Equipment, testing, etc.)

TOTAL ► -$

LINE

NO.

1B SUBCONTRACTOR

PROPOSAL

(VA FORM 10-3385b)1D

1E

ELECTRICAL -$

SPECIAL/GENERAL/CONSTRUCTION

3C

DIRECT

OVERHEAD

(Line 8)

TOTAL DIRECT COST ► -$

NET DIRECT COST (Line 8, Col.C - Col.B) ►

TOTAL CHANGE ORDER COST (Line 4 + 14) ► -$ -$

PROFIT

TOTAL PRIME CONTRACTOR COST ► -$ -$

-$ -$ (Line 5)

TAXES ON MATERIAL AND EQUIPMENT

11A

Profit, Overhead, and Fee Calculation in accordance with VAAR 852.236.88 (Jul 2002)VA FORM 08-3385a

CONSTRUCTION CHANGE ORDER COST SUMMARY

(PRIME CONTRACTOR)

Department of Veterans Affairs

PROPOSAL REQUEST NO. VA PROCEED ORDER NO. VA CHANGE ORDER NO.

ADDED WORK

(COST)

(C)

ITEM

(A)

SITE WORK

MECHANICAL AND HVAC

PROJECT NAMEPROJECT NO.

PROJECT LOCATION

CONTRACT NO. NAME OF PRIME CONTRACTOR

DESCRIPTION OF WORK

PRIME CONTRACTOR DIRECT LABOR

PRIME CONTRACTOR DIRECT MATERIAL

PRIME CONTRACTOR EQUIPMENT RENTAL

ESTIMATOR:

11C

TOTAL SUBCONTRACTOR COST ►

11B

10A

10B

10C

PROJECT LOCATION

CONTRACT NO. NAME OF SUBCONTRACTOR

CONSTRUCTION CHANGE ORDER COST SUMMARY

(SUBCONTRACTOR)

PROJECT NO. PROJECT NAME

LINE

NO.

ITEM

(A)

OMITTED WORK

(CREDIT)

(B)

ADDED WORK

(COST)

(C)

1 DIRECT LABOR -$

DESCRIPTION OF WORK

PROPOSAL REQUEST NO. VA PROCEED ORDER NO. VA CHANGE ORDER NO.

4 TOTAL DIRECT COST ► -$ -$

5 NET DIRECT COST (Line 4, Col. C - Col. B) ► -$

2 DIRECT MATERIAL -$

3 EQUIPMENT RENTAL -$

6B ON NEXT $30,000 -$ (Line 5) -$

6A

DIRECT

OVERHEAD

ON FIRST $20,000 -$ (Line 5)

6C ON BALANCE OVER $50,000 -$ (Line 5) -$

7A

PROFIT

ON FIRST $20,000 -$ (Line 5) -$

7B

8 INSURANCE AND TAXES 10.0% (Line 1) -$ -$

ON NEXT $30,000 -$ (Line 5) -$

7C ON BALANCE OVER $50,000 -$ (Line 5)

10 TOTAL ► -$ -$

11 COST PROPOSAL (Line 10, Col C - Col B) -$

9 TAXES ON MATERIAL AND EQUIPMENT 10.0% (Lines 2 and 3) -$ -$

ESTIMATOR: S. Kang DATE

VA FORM 08-3385b Profit, Overhead, and Fee Calculation in accordance with VAAR 852.236.88 (Jul 2002)

12 CREDIT PROPOSAL (Line 10, Col B - Col C) -$

REMARKS

852.236-88 Contract changes - supplement.

As prescribed in 836.578, insert the following clause:

CONTRACT CHANGES - SUPPLEMENT (JUL 2002)

The clauses entitled “Changes” in FAR 52.243-4 and “Differing Site Conditions” in FAR 52.236-2 are supplemented as follows:

(a) Paragraphs (a)(1) through (a)(4) apply to proposed contract changes costing over $500,000.

(1) When requested by the contracting officer, the contractor shall submit proposals for changes in work to the resident engineer. Proposals, to be submitted as expeditiously as possible but within 30 calendar days after receipt of request, shall be in legible form, original and two copies, with an itemized breakdown that will include material, quantities, unit prices, labor costs (separated into trades), construction equipment, etc.

(Labor costs are to be identified with specific material placed or operation performed.) The contractor must obtain and furnish with a proposal an itemized breakdown as described above, signed by each subcontractor participating in the change regardless of tier. When certified cost or pricing data are required under FAR Subpart 15.403, the cost or pricing data shall be submitted in accordance with FAR 15.403-5.

(2) When the necessity to proceed with a change does not allow sufficient time to negotiate a modification or because of failure to reach an agreement, the contracting officer may issue a change order instructing the contractor to proceed on the basis of a tentative price based on the best estimate available at the time, with the firm price to be determined later. Furthermore, when the change order is issued, the contractor shall submit a proposal, which includes the information required by paragraph (a)(1), for cost of changes in work within 30 calendar days.

(3) The contracting officer will consider issuing a settlement by determination to the contract if the contractor's proposal required by paragraphs (a)(1) or (a)(2) of this clause is not received within 30 calendar days o if agreement has not been reached.

(4) Bond premium adjustment, consequent upon changes ordered, will be made as elsewhere specified at the time of final settlement under the contract and will not be included in the individual change.

(b) Paragraphs (b)(1) through (b)(11) apply to proposed contract changes costing $500,000 or less:

(1) When requested by the contracting officer, the contractor shall submit proposals for changes in work to the resident engineer. Proposals, to be submitted as expeditiously as possible but within 30 calendar days after receipt of request, shall be in legible form, original and two copies, with an itemized breakdown that will include material, quantities, unit prices, labor costs (separated into trades), construction equipment, etc. (Labor costs are to be identified with specific material placed or operation performed.) The contractor must obtain and furnish with a proposal an itemized breakdown as described above, signed by each subcontractor participating in the change regardless of tier. When certified cost or pricing data or information other than cost or pricing data are required under FAR 15.403, the data shall be submitted in accordance with FAR 15.403-5. No itemized breakdown will be required for proposals amounting to less than $1,000.

(2) When the necessity to proceed with a change does not allow sufficient time to negotiate a modification or because of failure to reach an agreement, the contracting officer may issue a change order instructing the contractor to proceed on the basis of a tentative price based on the best estimate available at the time, with the firm price to be determined later. Furthermore, when the change order is issued, the contractor shall submit within 30 calendar days, a proposal that includes the information required by paragraph (b)(1) for the cost of the changes in work.

(3) The contracting officer will consider issuing a settlement by determination to the contract if the contractor's proposal required by paragraphs (b)(1) or (b)(2) of this clause is not received within 30 calendar days, or if agreement has not been reached.

(4) Allowances not to exceed 10 percent each for overhead and profit for the party performing the work will be based on the value of labor, material, and use of construction equipment required to accomplish the change. As the value of the change increases, a declining scale will be used in negotiating the percentage of overhead and profit. Allowable percentages on changes will not exceed the following: 10 percent overhead and 10 percent profit on the first $20,000; 7-1/2 percent overhead and 7-1/2 percent profit on the next $30,000; 5 percent overhead and 5 percent profit on balance over $50,000. Profit shall be computed by multiplying the profit percentage by the sum of the direct costs and computed overhead costs.

(5) The prime contractor’s or upper-tier subcontractor’s fee on work performed by lower-tier subcontractors will be based on the net increased cost to the prime contractor or upper-tier subcontractor, as applicable. Allowable fee on changes will not exceed the following: 10 percent fee on the first $20,000; 7-1/2 percent fee on the next $30,000; and 5 percent fee on balance over $50,000.

(6) Not more than four percentages, none of which exceed the percentages shown above, will be allowed regardless of the number of tiers of subcontractors.

(7) Where the contractor's or subcontractor’s portion of a change involves credit items, such items must be deducted prior to adding overhead and profit for the party performing the work. The contractor’s fee is limited to the net increase to contractor of subcontractors’ portions cost computed in accordance herewith.

(8) Where a change involves credit items only, a proper measure of the amount of downward adjustment in the contract price is the reasonable cost to the contractor if he/she had performed the deleted work. A reasonable allowance for overhead and profit are properly includable as part of the downward adjustment for a deductive change. The amount of such allowance is subject to negotiation.

(9) Cost of Federal Old Age Benefit (Social Security) tax and of Worker’s Compensation and Public Liability insurance appertaining to changes are allowable. While no percentage will be allowed thereon for overhead or profit, prime contractor’s fee will be allowed on such items in subcontractors’ proposals.

(10) Overhead and contractor’s fee percentages shall be considered to include insurance other than mentioned herein, field and office supervisors and assistants, security police, use of small tools, incidental job burdens, and general home office expenses and no separate allowance will be made therefore. Assistants to office supervisors include all clerical, stenographic and general office help Incidental job burdens include, but are not necessarily limited to, office equipment and supplies, temporary toilets, telephone and conformance to OSHA requirements. Items such as, but not necessarily limited to, review and coordination, estimating and expediting relative to contract changes are associated with field and office supervision and are considered to be included in the contractor’s overhead and/or fee percentage.

(11) Bond premium adjustment, consequent upon changes ordered, will be made as elsewhere specified at the time of final settlement under the contract and will not be included in the individual change.

(End of Clause)

VA Greater Los Angeles Healthcare System Interim Life Safety Measures Assessment

See ILSM requirements at the end of this document before completing this form (ILSM Is Good For the Duration of Construction)

To be filled out by the contractor prior to start of Construction and provided to COR

Date: ________________________ Facility: __________________________Project Name: _______________________

Start Date: _____________ Superintendant: ___________________________ Phone Number: _____________________

Project Location: _______________________________________________Project Number: _______________________

Description of work to be performed:

Use the following criteria to determine appropriate Interim Life Safety Measures (ILSM) for your project. (See the end of this document for a description of ILSM requirements).

1. Will all exits be free from obstructions?

Yes. No further action required. No. Post conspicuous signs directing occupants to alternate exit. Distribute notices to occupants advising them of designated exit.

**Does the hospital post signage identifying the location of alternate exits to everyone affected?

2. Will the fire alarm system remain in good working order?

Yes. No further action required. No. A fire watch must be implemented. Fill out a fire watch implementation form and submit to security for execution.

**Does the hospital notify the fire department (or other emergency response group) and initiate a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building?

3. Will the fire-suppression systems (sprinklers) remain in good working order?

Yes. No further action required. No. A fire watch must be implemented. Fill out a fire watch implementation form and submit to security for execution.

**Does the hospital notify the fire department (or other emergency response group) and initiate a fire watch when a fire alarm or sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building?

4. Will temporary construction barriers be used in this project?

Yes. Must be built smoke-tight and constructed of noncombustible, or limited combustible materials.

No. No further action required.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital use temporary construction partitions that are smoke tight, or made of vhaglasubhan

Rectangle noncombustible material, or made of limited-combustible material that will not contribute to the development or spread of fire?

5. Will additional portable fire extinguishers be provided?

Yes. No further action required. No. Obtain a spare 10-lb. ABC fire extinguisher and place in conspicuous location in project area.

**The contractor shall provide fire extinguishers (10 lbs ABC) in the construction site. The extinguishers shall be properly mounted and checked monthly.

6. Will packaging, debris, and discarded materials be removed daily to minimize combustible loads?

Yes. No further action required. No. STOP! All discarded material must be removed daily to minimize combustible loads.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital enforce storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level?

7. Will additional fire drills be required in affected areas, due to change in exiting or other impairments?

Yes. Notify safety officer for implementation. No. No further action required.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital conduct one additional fire drill per shift per quarter?

8. Will increase hazard surveillance of the project area be conducted daily by the project manager?

Yes. No further action required. No. STOP! The project manager must perform increased hazard surveillance of the project area on a daily basis.

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital increase surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices?

10. Will building occupants need to be trained to compensate for impaired Life Safety features?

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital provide additional training to those who work in the hospital on the use of fire-fighting equipment?

11. Will an organization-wide safety education program be required to promote awareness of hazards?

**Does the hospital conduct education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety?

12. Will temporary systems be tested or inspected on a monthly basis?

Yes. No further action required. No. STOP! Temporary systems must be tested or inspected monthly.

N/A (No systems will be affected)

**When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, does the hospital inspect and test temporary systems monthly? Is the completion date of these tests documented?

ILSM Assessment Completed By (PRINT): __________________________________________________

Signature: _______________________________________ Date: ___________________________________

Description of Interim Life Safety Measures to be Implemented

Based on the responses to the evaluation questions, provide a description of the Interim Life Safety measures that will be implemented during the project to compensate for the deficiency or condition.

Project COTR Date

Contractor or M&O Representative Date

Safety Officer or Designee Date

ILSM Requirements ILSM are a series of eleven administrative actions required to be taken to temporarily compensate for the hazards posed by existing LSC deficiencies or construction activities.

(1) Ensure exits provide free and unobstructed egress. Employees shall receive training if alternative exits must be designed.

(2) Ensure free and unobstructed access to emergency department and for emergency forces.

(3) Ensure fire alarm, detection, and suppression systems are not impaired. A temporary, but equivalent, system shall be provided when any fire system is impaired. Temporary systems must be inspected and tested monthly. (4) Ensure temporary construction partitions are smoked tight and built of noncombustible materials.

(5) Provide additional firefighting equipment and use training for employees within affected area.

(6) Smoking shall be prohibited in or adjacent to all construction areas within the healthcare system.

(7) All storage in areas that are sprinklered shall be kept 18" inches below the sprinkler head. There will be no storage of any type in halls, passageways, or walkways.

(8) All empty boxes, trash, and waste will be properly disposed of in approved waste storage bins provided by Environmental Management Department. All work areas shall be kept clean and free of debris and unnecessary flammable materials at all times.

(9) Additional fire drills will be conducted in the areas affected by ILSMs until the ILSMs are rescinded.

(10) Increase hazard surveillance in the area affected by ILSMs until the ILSMs are rescinded.

(11) Training will be provided to all employees in the area affected by ILSMs to ensure that these employees understand the ILSMs and that the new fire/emergency procedures that have been implemented.

ILSM Educational Awareness Worksheet (Contractor to coordinate time and date with COR)

Notification for staff in areas affected by ILSM implementation.

(to be filled out by contractor)

Date: _______________

Building/Floor/Locations of Notification: _______________________________________________

Location of Construction: ________________________________________________________

Type of ILSM’s implemented: ________________________________________________________

Content

Overview

Notification for all employees who are affected by Interim Life Safety Measures.

Objectives After completing the training, employees will be able to recognize and understand interim life safety measure to be determined.

Scenario Fire Alarm and/or Sprinkler System disabled: Employees were re-oriented on the fire procedures and the location of the fire apparatus. Operator will be contacted using the phone and dialing “12” (WLA), “3” (Sepulveda) “2222” (LAACC), if alarm is disabled. All employees had the emergency numbers given to them.

BLOCKING OFF AN APPROVED EXIT: Employees were oriented on the alternative exit(s), reference attached drawings, pictures and/or layouts.

Educational

Awareness

a. Personnel/Patients/Visitors adhere to temporary construction and/or Interim Life Safety Measure signs posted.

b. Re-orientate employees on the proper evaluation routes in their immediate work areas.

c. Enforce good storage and housekeeping practices.

d. Ensure Exits maintain clear and unobstructed at all time.

e. Prohibit smoking.

Problems to

Watch For

a. Corridor and exit routes obstructed

b. Smoking

c. Dust and dir ty corr idors from construction workers

Orientation On a. Special Precautions, Signs, PPE, etc.

b. Temporary partitions, re-routing of exits.

Service/Departments: ______________________________________________________

Employees Notified:

(Fill out names of all employees attending training and/or receiving notification)

1. __________________________ 16. ____________________________

2. __________________________ 17. ____________________________

3. __________________________ 18. ____________________________

4. __________________________ 19. ____________________________

5. __________________________ 20. ____________________________

6. __________________________ 21. ____________________________

7. __________________________ 22. ____________________________

8. __________________________ 23. ____________________________

9. __________________________ 24. ____________________________

10. __________________________ 25. ____________________________

11. __________________________ 26. ____________________________

12. __________________________ 27. ____________________________

13. __________________________ 28. ____________________________

14. __________________________ 29. ____________________________

15. __________________________ 30. ____________________________

Name of Instructor Date

(Contractor or COR)

Date:

Facility:

Project Name:

Start Date:

Superintendant:

Phone Number:

Project Location:

Project Number:

Description of work to be performed 1:

undefined_3:

undefined_5:

undefined_6:

undefined_8:

undefined_9:

undefined_10:

undefined_12: Off undefined_14:

undefined_15:

undefined_17:

undefined_18:

undefined_19:

undefined_20: Off undefined_22:

undefined_23:

undefined_24:

undefined_25: Off undefined_26:

undefined_27: Off undefined_29:

undefined_30: Off undefined_31:

ILSM Assessment Completed By PRINT:

Date_2:

that will be implemented during the project to compensate for the deficiency or condition 1:

Project COTR:

Date_3:

Contractor or MO Representative:

Date_4:

Safety Officer or Designee:

Date_5:

Date_6:

BuildingFloorLocations of Notification:

1_2:

Location of Construction:

Type of ILSMs implemented:

1_3:

ServiceDepartments 1:

ServiceDepartments 2:

1_4:

Name of Instructor:

Date_7:

X:

16:

TEST AND INSPECTION REQUEST

A.

B.

Test Required by (name of contractor)

Date of Inspection Request

Date of Inspection Required

Date of Inspection Completed

Inspector’s Name

C.

Test/ Inspection Requested:

Choose an item.

Drawing Page/ Detail:

Inspector Comments, Exception and/or Approvals

Re-inspection required:

If Yes, describe re-inspection requirement

YES NO

I hereby declare under penalty of perjury that all above statements are true and to the best of my personal knowledge the work herein described by this report has been performed and installed in compliance with the approved plans, specifications and all applicable codes and standards.

Inspector/ Certified Person Signature Date

Facility Name

Project #

Project Title

Project Location (bldg. & rm #)

Facility Name:

Project:

Project Title:

Project Location bldg rm:

Test Required by name of contractor:

Date of Inspection Request:

Date of Inspection Required:

Date of Inspection Completed:

Inspectors Name:

Test Inspection Requested Choose an item:

Drawing Page DetailInspector Comments Exception andor Approvals:

Reinspection required If Yes describe reinspection requirement:

Text28:

Check Box29: Off

Check Box30: Off

Text31:

Text32:

Confined Space Entry Permit

A.

Facility Name Project #

Project title Project Location

B.

Space Name Purpose of Entry

Entry # Entry Date Entry Time

Permit Expires Rescue Info Phone #

Attendants

Entrants

C. HAZARDS

Yes NO

1 Hazard identified

2 Oxygen deficiency (less than 19.5% at sea level)

3 Flammable gases or vapors (greater than 10% of the lower limit, or greater than 23% oxygen at sea level)

4 Toxic gases or vapors (greater than the permissible exposure limit)

5 Mechanical hazards

6 Electrical hazards

7 Material harmful to skin

8 Engulfment

9 Configuration

D. EQUIPMENT

1 Respiratory Protection

2 Protective Clothing/ Equipment

3 Communication Equipment

4 Rescue Equipment

5 Ventilation

6 Electrical Equipment

E.HAZARD CONTROLS (Specify)

1 Isolate the space

2 Lockout

3 Clean/Purge

4 Ventilate

5 Barriers

6 Others

Facility Name:

Project:

Project title:

Project Location:

Space Name:

Purpose of Entry:

Entry:

Entry Date:

Entry Time:

Permit Expires:

Rescue Info:

Phone:

Attendants:

Entrants:

YesHazard identified:

NOHazard identified:

YesOxygen deficiency less than 195 at sea level:

NOOxygen deficiency less than 195 at sea level:

3:

YesFlammable gases or vapors greater than 10 of the lower limit or greater than 23 oxygen at sea level:

NOFlammable gases or vapors greater than 10 of the lower limit or greater than 23 oxygen at sea level:

YesToxic gases or vapors greater than the permissible exposure limit:

NOToxic gases or vapors greater than the permissible exposure limit:

YesMechanical hazards:

NOMechanical hazards:

YesElectrical hazards:

NOElectrical hazards:

YesMaterial harmful to skin:

NOMaterial harmful to skin:

YesEngulfment:

NOEngulfment:

YesConfiguration:

NOConfiguration:

YesRespiratory Protection:

NORespiratory Protection:

YesProtective Clothing Equipment:

NOProtective Clothing Equipment:

YesCommunication Equipment:

NOCommunication Equipment:

YesRescue Equipment:

NORescue Equipment:

YesVentilation:

NOVentilation:

YesElectrical Equipment:

NOElectrical Equipment:

YesIsolate the space:

NOIsolate the space:

YesLockout:

NOLockout:

YesCleanPurge:

NOCleanPurge:

YesVentilate:

NOVentilate:

YesBarriers:

NOBarriers:

YesOthers:

NOOthers:

GLA After-Working-Hours Activity Security Form

Project Name:______________________________________________________________

Location of Activity: Bldg._________ Floor __________ Wing _________ Room_________

Contractor’s Name:________________________________________________________

There will be activity after normal working hours.

Date:Click here to enter a date. Hours:____________ to _______________

The following persons will be involved:

1.____________________________ DL # _____________________________________

2.____________________________ DL # _____________________________________

3. ____________________________ DL# _____________________________________

4.____________________________ DL # _____________________________________

Superintendent in Charge: _________________________________________________

Phone: _______________________________

Cell:_________________________________

You are directed to check in and out in Room __________ with the VA medical Center Police, who will assist as necessary.

Project Manager _____________________________________________________________

Approved: _________________________________________________ VA Police Ext 44471

Project Name:

Location of Activity Bldg:

Floor:

Wing:

Room:

Contractors Name:

Hours:

to:

1:

DL:

2:

DL_2:

3:

DL_3:

4:

DL_4:

Superintendent in Charge:

Phone:

Cell:

You are directed to check in and out in Room:

Project Manager:

Approved:

8/19/2013

Infection Control Permit & Pre-Construction Risk Assessment yyyyyyyy Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work: Telephone:

Supervisor:

Email:

Project or Work Order #

Description of project: (Choose only one.) Demolition Construction Renovation Repairs

Type A Inspections and Non-Invasive Activities or Small scale, Short duration Activities

Yes No

Removal of ceiling tiles for visual inspection (limited to <25% of total area) Painting (limited sanding to <10% of area) Wall covering—Describe work to be done:

Electrical trim work. Describe:

Minor plumbing. Describe:

Type B Small scale, short duration activities that create minimal dust.

Installation of telephone and computer cabling Access to chase spaces

Sanding of walls for painting or wall covering (minor repairs—not sanding for drywall finishing)

Type C Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies.

Sanding of walls-(>50% of surface area)-drywall finishing Removal of floor coverings ceiling tile casework (>50% of surface area) Describe:

% Describe: Cutting of walls or ceiling. Describe:

New wall construction

Minor ductwork or electrical work above ceilings Major cabling activities

Activity cannot be completed within a single work shift Type D Major demolition and construction projects.

Will require heavy demolition or removal of a complete ceiling system

New construction

Group 1 Lowest Risk

Group 2 Medium Risk Group 3 Medium-High Risk Group 4 Highest Risk

Office Areas

Ambulatory Care

Emergency room

Operating Rooms, Clean and Soiled

Non-patient Care

Radiology/MRI

Utility Areas

Areas

Day Surgery

Supply, Processing or Distribution

PACU

Areas/DSU

All Intensive Care Units

Cardiovascular Procedure Areas

Nuclear Medicine

Cardiac Cath and Angioplasty Areas

Admission

Procedure Rooms

PT, Pool/Water Therapy

Isolation Rooms

Housekeeping Closets

Dialysis

Dietary Storage

Cardiology

Food Preparation Areas

Anesthesia and Pump Areas

Canteens

Pharmacy Admixture Area

Laboratories Interstitials in Group 3

Endoscopy Areas Interstitials in Group 4

Respiratory Therapy Patient Units: (Mental Health, Medicine, Rehab)

CONSTRUCTION ACTIVITY (from previous page)

Check type of activity INFECTION CONTROL RISK GROUP (see above) Check risk group

TYPE A: Inspection, non-invasive activity GROUP 1: Lowest Risk

TYPE B: Small scale, short duration projects; minimal dust

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust, requiring >1 work shift for completion; demolition or removal of any fixed bldg components or assemblies

GROUP 3: High Risk

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

GROUP 4: Highest Risk

CLASSIFICATION OF REQUIRED PREVENTIVE MEASURES

CONSTRUCTION

ACTIVITY-INFECTION CONTROL

RISK GROUP

"A"

TYP E

"B"

TYPE

"C"

"D"

"D"Group I I

"A"

I II III/IV

Group 2 I I III IV

Group 3 II III III/IV IV

Group 4 III III/IV III/IV IV

An Infection Control Construction Permit is required for any work done in Class III or IV. Refer to shaded area on Classification of Required Prevention Measures above.

CLASS I

1.

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

2.

Immediately replace any ceiling tile displaced for visual inspection.

CLASS II

1. Provide active means to prevent air-borne 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. Wipe surfaces with disinfectant.

6. Contain construction waste before and during transport in tightly covered containers.

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

8. Place dust mat at entrance and exit of work area as needed.

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

CLASS III

1. Obtain infection control permit before construction begins.

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

3. Complete all critical barriers before construction

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

5. Contain construction waste before and during transport in tightly covered containers.

cleaned.

6. Seal holes, pipes, conduits, etc. appropriately.

7. Place dust mat at entrance and exit of work area. Replace as needed.

8. Do not remove barriers from work area until completed project is inspected by Safetly and Epidemiology Depts. and thoroughly cleaned.

After work is completed:

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

10. Remove isolation of HVAC system.

Class IV 7

1. Obtain infection control permit before construction

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

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative air pressure within work site utilizing

HEPA equipped air filtration units.

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

6. 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 the work site.

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

8. Contain construction waste before and during transport in tightly covered containers. Cover transport receptacles or carts. Tape covering.

9. Do not remove barriers from work area until completed project is inspected by Safety and Epidemiology Depts. And thoroughly cleaned.

After work is completed:

10. Vacuum work area with HEPA filtered vacuums.

11. Wet mop with disinfectant.

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

13. Remove isolation of HVAC system.

Additional concerns for all classes:

1. Maintain manpower and equipment including dust mops, wet mops, brooms, buckets, and clean wiping rags for cleaning fine dust from floors and adjacent occupied areas.

2. Contain work areas outside of construction barriers, including spaces above ceilings, with full height polyethylene sheet barrier, tightly taped. No work of any sort may be started without the barriers in place.

3. Clean up dust tracked outside of construction area immediately.

4. Temporary construction barriers and closures above ceiling must be dust tight.

5. Removal of debris must be in covered containers.

SIGNATURE DATE

Location of Construction:

Project Start Date:

Project Coordinator:

Estimated Duration:

Contractor Performing Work:

Telephone:

Supervisor:

Demolition: Off

Construction: Off

Renovation: Off

Repairs: Off

YesRow1:

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CONSTRUCTION ACTIVITY from previous page Check type of activityRow1:

INFECTION CONTROL RISK GROUP see above Check risk groupTYPE A Inspection noninvasive activity:

CONSTRUCTION ACTIVITY from previous page Check type of activityRow2:

INFECTION CONTROL RISK GROUP see above Check risk groupTYPE B Small scale short duration projects minimal dust:

CONSTRUCTION ACTIVITY from previous page Check type of activityRow3:

INFECTION CONTROL RISK GROUP see above Check risk groupTYPE C Activity generates moderate to high levels of dust requiring 1 work shift for completion demolition or removal of any fixed bldg components or assemblies:

CONSTRUCTION ACTIVITY from previous page Check type of activityRow4:

INFECTION CONTROL RISK GROUP see above Check risk groupTYPE D Major duration and construction activities Requiring consecutive work shifts:

DATE:

email:

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INFECTION CONTROL ROUNDS CHECKLIST

Location: Project # Date:

Contractor:

Class of Precautions I II III IV

Class I, II, III, IV Methods in place to minimize dust raising Appropriate signage on doors to construction area Appropriate debris transport i.e.: covered cart, dedicated elevator, dedicated route, etc.

Area cleaned at end of the day/trash to designated area No visible signs of mice, insects, birds or other vermin Roof protection in place for projects on roof Displaced ceiling tiles immediately replaced Traffic pattern discourages patient exposure Water disruptions, if needed, are scheduled during low activity

Class II, III, IV Barrier is solid and airflow goes from clean to dirty Surfaces water-misted to control dust while cutting Unused doors sealed with duct tape Air vents blocked off and sealed Walk off mats at work areas- kept wet throughout the day Floors not showing visible track dirt outside const. area HVAC system for this area is sealed or isolated

Class III, IV Critical barriers to seal area in place before beginning Negative air pressure maintained with HEPA equipped units

Waste contained in tightly covered containers Transport carts sealed with tape if not a solid lid

Class IV Patients relocated away from construction area HVAC system for this area is isolated Holes, pipes, conduits and punctures are sealed appropriately

Anteroom present and all personnel are required to pass through and be vacuumed with HEPA vacuum prior to leaving the site OR they wear cloth or paper coveralls that are removed each time they leave the site.

Barriers in place until final inspection by Safety and IC and cleaning by ECS

INFECTION CONTROL DURING CONSTRUCTION AND RENOVATION PROJECTS

A. GENERAL:

(1) Construction will be conducted in tight enclosures cutting off any flow of particles into patient areas. Where appropriate, and before construction on site begins, the Contractor's on-site management team shall participate in joint planning with GLAHS' Engineering Project Management, and infection Control Department for dust control measures and instruction on precautions required. GLAHS requires any Contractor, Sub-Contractors, material suppliers, vendors, employees, or agents to be bound by these same requirements. Specific infection control measures are determined by project classification.

(2) HEPA equipped air filtration machines shall provide air flow into construction area not less than 100 FPMs at barricade entrances with doors fully open. HEPA equipped air filtration machines shall be connected to normal power and ganged to a single switch for emergency shutoff and shall run continuously.

(3) The GLAHS' Safety or Infection Control Departments may modify performance requirements for certain activities. Any modifications made by GLAHS' personnel do not relieve the Contractor of compliance with proper infection control procedures.

(4) The Contractor is responsible for maintaining equipment and replacement of HEPA and other filters in accordance with manufacturer's recommendations.

B. INFECTION CONTROL PERMIT:

(1) An Infection Control Permit is required for all Class III and higher projects and any activity in Infection Control Risk Group 4. Refer to shaded areas on Pre-Construction Risk Assessment, Classification of Required Preventive Measures.

(2) The Infection Control Permit will be obtained from the Infection Control Department in bldg. 500, Room 6404, prior to beginning any demolition or construction work.

(3) The Permit will be displayed at the entrance to the work area during the entire construction period.

C. PRODUCTS AND MATERIALS:

(1) Sheet Plastic: Fire retardant polystyrene, 6-mil thickness.

(2) Barrier Doors: Solid core wood in metal frame, painted.

(3) HEPA Equipped Air Filtration Machines: Forced Air 2000 HEPA equipped air filtration as well as primary and secondary HEPA filters.

(4) Exhaust Hoses: Heavy duty, flexible, steel, and reinforced.

(5) Adhesive Walk-Off Mats.

(6) Disinfectant: GLANS approved disinfectant or equal.

D. BARRIERS:

(1) Closed door with masking tape applied over the frame and door is acceptable for projects that can be contained.

(2) Construction, demolition or reconstruction not capable of containment within a single room must have the following barriers erected:

(a) Airtight plastic barrier that extends from floor to ceiling. Seams must be sealed with duct tape to prevent dust and debris from escaping.

(b) Drywall barriers erected with joints covered or sealed to prevent dust and debris from escaping.

(c) Seal (airtight) all penetrations in existing barrier.

(d) Barriers at penetration of ceiling envelops, chases and ceiling spaces to stop movement of air and debris.

(e) Anteroom or double entrance openings that allow workers to removed protective clothing or vacuum off existing clothing.

(f) At elevator shafts or stairways within the field of construction.

(g) Overlapping flap (minimum 2 feet wide) at polyethylene enclosures for personnel access.

E. IMPLEMENTATION:

(1) Adhesive mats or carpets at barricade entrances and in the anteroom shall be kept clean and changed daily, or as necessary, to prevent accumulation of dust.

(2) Any dust tracked outside of barriers shall be removed immediately, and outside cleaned by vacuuming with NEPA filter or damp mop.

(3) Any ceiling access panels opened for investigation beyond sealed areas shall be replaced immediately when unattended.

(4) Block off all existing ventilation ducts within the construction area. Method of capping ducts shall be dust tight and withstand airflow.

(5) Construct anteroom to maintain negative airflow from clean area through anteroom and into work area.

Contractor:

Location:

Project#:

Date:

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THIS PERMIT SHALL BE RETURNED TO THE FIRE & SAFETY OFFICE AT COMPLETION OF WORK.

HOT WORK PERMIT

Before initiating hot work, ensure precautions are in place as required by NFPA 51B and ANSI Z49.1.

This Hot Work is required for any operation involving open flame or producing heat and/or sparks. This work includes, but not limited to, welding, brazing, cutting, grinding, soldering, thawing pipe, torch-applied roofing, tar kettles, or chemical welding.

(PERMIT GOOD FOR 24 HOURS FROM DATE AND TIME OF ISSUE.) Date:___________

Hot work being done by:

VA Employee: ____________________________

Contractor: ______________________________ Cell Phone #: _____________________________

Signature: __________________________________

**REQUIRED PRECAUTIONS CHECKLIST**

***************CHECK ALL THAT APPLY*********

Available sprinklers, hose streams and extinguishers are in good service and tagged.

Hot work equipment in good repair.

**Requirements within 35 feet of work**

Flammable liquids, dust, lint and oil deposits removed.

Floors swept clean.

Combustible floors wet down, covered with damp sand or fire-resistant sheets.

Remove other combustibles where possible.

*Otherwise protect with tarpaulins suspended beneath work.*

All wall and floor openings covered.

Fire-resistant tarpaulins suspended beneath work.

**Work on walls or ceilings/enclosed equipment**

Construction is non-combustible and without combustible covering or insulation.

Combustible on other side of walls moved away.

Danger exists by conduction of heat into another area.

Enclosed equipment cleaned of all combustibles.

Containers purged of flammable liquids/vapors.

**Fire watch shall be provided with suitable extinguisher**

Fire watch shall be provided during and for 30 minutes after work, including coffee or lunch breaks.

Fire watch is trained in use of this equipment and in sounding he alarm.

Fire watch may be required for adjoining areas, above and below.

Monitor hot work area for 30 minutes after job is completed.

**Other Precautions Taken**

Confined space entry permit required?

Is area protected with smoke/heat detection?

Ample ventilation to remove smoke/vapor from work?

Lockout/Tagout required?

Date: _____________Time work Starts: _________

Estimated Time Work Completed: _________

Location/Building and Floor:

Nature of work to be performed:

I verify the above location has been examined; the precautions checked on the “Required Precautions Checklist” have been taken to prevent fire and permission is authorized for Hot Work.

Signed: ____________________________________ Fire & Safety Specialist

Permit Expires:

Date: _____________ Time: _____________ AM

PM

**AT COMPLETION OF FIRE WATCH**

Signature of fire watch: ___________________________

Dated: ________________ Time: ___________________

THIS PERMIT SHALL BE

RETURNED TO THE FIRE &

SAFETY OFFICE AT

COMPLETION OF WORK.

Building 218, Room 310, Telephone: 310-268-3563

VA West Los Angeles

Procedures for Reporting Fires

1) By activating the nearest manual alarm pull station.

2) Dial Fire number ‘12’ and report the incident to the VA Telephone Operator. Give your name, exact location of the fire and explain if possible what is burning.

3) False alarms shall be reported by notifying the Fire and Safety Office either by telephone at extension 83563 or by Group Page through VA Telephone Operators.

4) It is important to report all fires (no matter how small or large) to the Fire and Safety Office.

5) VA Police Emergency Number is extension 2804.

6) All other Emergencies Phone Number is extension 7000.

VA Sepulveda

2) Dial Fire number ‘3’ and report the incident to the VA Telephone Operator. Give your name, exact location of the fire and explain if possible what is burning.

3) False alarms shall be reported by notifying the Fire and Safety Office either by telephone at 310-268-3563 or by Group Page through VA Telephone Operators.

4) It is important to report all fires (no matter how small or large) to the Fire and Safety Office at 310-268- 3563.

5) VA Police Emergency Number is Extension 9300.

6) All other Emergencies Phone Number is Extension 9300.

VA Los Angeles Ambulatory Care Center (LAACC)

2) Dial Fire number ‘2222’ and report the incident to the VA Telephone Operator. Give your name, exact location of the fire and explain if possible what is burning.

3) False alarms shall be reported by notifying the Fire and Safety Office either by telephone at 310-268-3563 or by Group Page through VA Telephone Operators.

4) It is important to report all fires (no matter how small or large) to the Fire and Safety Office at 310-268-3563.

5) VA Police Emergency Number is Extension 4036.

5) All other Emergencies Phone Number is Extension 4036.

Hot work being done by:

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Date:

Time work Starts:

Estimated Time Work Completed:

LocationBuilding and Floor:

Nature of work to be performed 1:

Signed:

Date_2:

Time:

Dated:

Time_2:

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VA Greater Los Angeles

Healthcare System

Interstitial Work Permit

(Return all Permits and Signature Forms to _________________________, B-218)

Date issued: ______________________________ Issued to (Name): ___________________________________

Engineering Department and Telephone: ___________________________________________________________

Company Name and Telephone: _________________________________________________________________

Start date: ________________________________ Estimated Completion: ________________________________

Work requested by: _______________________________ Name: ______________________________________

Location work to be performed: ______________________________________ Interstitial Floor: _____________

Area/Section: _________________________________________________________________________________

Type of work to be performed: ____________________________________________________________________

Dust, netting and planking containment used: ____ Yes ____ No ____ N/A

Interstitial Rules of Conduct reviewed and signed (By all workers)? ____ Yes ____ No

Engineering Representative: _______________________________________ Date: _______________________

Company Representative: _________________________________________ Date: _______________________

Area Inspection:

Work area inspected: ____ Yes ____ No

All penetrations properly Fire Stopped? ____ Yes ____ No _____ N/A

Are electrical panel/covers replaced? ____ Yes ____ No _____ N/A

Are all doors closed: ____ Yes ____ No _____ N/A

Area cleaned of trash? ____ Yes ____ No

I hereby certify that I have inspected the work area and find it to be in order.

Inspected by: _______________________ _________________________ Date: _______________________

Print Name Signature

VA Greater Los Angeles

Healthcare System

Occupants (Floor Below) Notified of Work Being Done

Occupants Signatures: Department: Extension:

Bldg. 500 Interstitial Rules of Conduct

Before accessing the interstitial, every individual must read and pledge that they will adhere to the following rules while working in the interstitial areas:

1. Yelling, loud conversation and profane language will not be tolerated.

Conversation will be kept to the minimum necessary to perform the work.

2. No interstitial stairwell access door, or interstitial interior door, will ever be left open or unlatched.

3. Extension (power) cords will never be run through the interstitial access doors and into the building stairwells.

4. No tools, materials, equipment, etc. will be left inside any building stairwell.

5. Noise from tools and machinery will be kept to the minimum possible.

6. Appropriate physical barrier(s) will be erected to prevent heavy tools, equipment, materials, dust or debris from accidentally falling through unprotected areas of the interstitial to the floor below.

7. All work will be scheduled to interrupt the operations of the area being repaired to the least extent possible.

8. The schedule of work will be shared with nearby occupants as early in the process as is feasible.

I have read the above rules of conduct and will abide by them:

PRINT NAME SIGNATURE DATE

Date issued:

Issued to Name:

Engineering Department and Telephone:

Company Name and Telephone:

Start date:

Estimated Completion:

Work requested by:

Name:

Location work to be performed:

Interstitial Floor:

AreaSection:

Type of work to be performed 1:

Type of work to be performed 2:

Engineering Representative:

Date:

Company Representative:

Date_2:

Inspected by:

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Date_3:

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Department 1:

Extension 1:

Above Ceiling Work Permit

Date issued: ______________________________ Issued to (Name): ___________________________________

Company Name and Telephone: _________________________________________________________________

Contractor’s Name____________________________________________ Signature_______________________

Start date: ________________________________Estimated completion: ________________________________

Location of work to be performed (Bldg/ Floor/ Rm #.): ____________________________________________

Area/Section: ____________________________________

Type of work performed:

Electrical Data Telephone Other Cables Medical Gases Piping Air Conditioning Seismic Insulation work Lighting Fire systems Nurse Call Tube systems Plumbing systems Sewer systems Fire Stopping

Dust containment system used: ___ Yes ___ No

HEPA filter/Exhaust system used: ___ Yes ___ No

Permit issued by (Dept.): _________________________________ Name: ________________________________

Inspection by Project Engineer/COR or Engineering/ Safety Staff:

Work inspected:

Location: ______________________________________________________________________

Were rated walls penetrated? ___ Yes ___ No

All penetrations properly Fire Stopped? ___ Yes ___ No

Are ceiling tiles back in place? ___ Yes ___ No

I hereby certify that I have inspected the work described above and find it to be free of any open wall penetrations, and ceiling penetrations and that all ceiling tiles are returned in place.

Print Name: ______________________________________________ Date: _______________________

Signature: _______________________________________________ Date: _______________________

VA Greater Los Angeles Healthcare

System

Date issued:

Issued to Name:

Company Name and Telephone:

Contractors Name:

Start date:

Estimated completion:

Location of work to be performed Bldg Floor Rm:

AreaSection:

Permit issued by Dept:

Name:

Location:

Print Name:

Date:

Date_2:

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