Off Hours Work Request Form.pdf

Off Hours Request White River Junction VA Medical Center (405)

163 Veterans Drive, White River Junction, VT 05001 802-295-9363 https://www.va.gov/white-river-junction-health-care/

WRJ Facilities Management Service WRJ FMS Form XXX-XX

Date:

From:

Subject:

To:

1. Contractor Afformation

I hereby request permission to perform work at the White River Junction Veterans Affairs Medical Center, White River Junction during non-administrative hours. I certify that all work to be performed is covered by current contract documents or approved changes, and that no additional cost will be incurred to the VA. I agree to show this signed permit to anyone on demand and realize that failure to produce this could result in expulsion from the hospital grounds. In addition to the contract requirements, I agree to abide by all the hospital regulations with regards to parking, traffic control, safety, infection control, security, etc.

Contractor Representative Name

Contractor Representative Signature Date

Emergency Contact Name Phone Number

Police

Safety

Engineer

Contracting

Off Hours Request White River Junction VA Medical Center (405)

163 Veterans Drive, White River Junction, VT 05001 802-295-9363

WRJ Facilities Management Service WRJ FMS Form XXX-XX

2. The following information from the Contractor is necessary before the request can be considered:

Project Number and Title:

Contract Number:

Location of Work:

Contractor Name:

Contractor Phone Number (after hours) :

Contractor’s Representative:

Off Hours Work Start: Date: Time:

Off Hours Work End: Date: Time:

Brief Description of Work Activities:

FOR VA USE

VA Engineering Action Approved Disapproved Reason for Disapproval:

Comments:

Project Engineer/COR Signature Date