Utility Shutdown Request Form.pdf
PDF 178 KB Posted
- Attached to
- Z2DA--EHRM Upgrades - White River Junction, VT
- Solicitation number
- 36C77626R0092
About this file
This is a Utility Shutdown Request form used by the White River Junction VA Medical Center (facility 405) located in White River Junction, Vermont to authorize contractors to perform work requiring the shutdown of critical utilities.
The form requires contractor affirmation that all work is covered by current contract documents or approved changes with no additional cost to the VA. Contractors must certify compliance with all safety protocols including Lockout/Tagout, personal protective equipment, dust and noise mitigation, and infection control measures, as well as hospital regulations regarding parking, traffic control, safety, and security. The contractor must provide emergency contact information for police, safety, engineering, and contracting personnel, and acknowledge that the VA Medical Center reserves the right to delay or cancel the shutdown at any time to protect patients, staff, and operations. Section 2 requires detailed project information including project number and title, contract number, work location, contractor identification, shutdown start and end dates with times, description of work activities, identification of affected utilities with panel and equipment numbers, detailed description of impacted areas by building and department, and mitigation efforts. The form includes a VA Engineering Action section for approval or disapproval with space for the Project Engineer/Contracting Officer's Representative signature and date.
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Text version
Utility Shutdown 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 Affirmation
I hereby request permission to perform work requiring shutdown of a critical utility at the White River Junction Veterans Affairs Medical Center. 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.
I affirm that all necessary safety protocols, including Lockout/Tagout, personal protective equipment, dust and noise mitigation, and infection control measures, will be properly implementd and maintained.
I understand that the VA Medical Center reserves the right to delay or cancel the shutdown at any time to protects patients, staff, and operations.
Contractor Representative Name
Contractor Representative Signature Date
Emergency Contact Name Phone Number
Police
Safety
Engineer
Contracting
Utility Shutdown 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 :
Contractor’s Representative:
Shutdown Start: Date: Time:
Shutdown End: Date: Time:
Brief Description of Work Activities:
Utilities Affected (electrical, HVAC, water, medical gas, fire supression, etc…). Include panel # & equipment #
Areas impacted by shutdown. Provide as much detail as possible. (Building, Room numbers, Departments, etc…)
Mitigation of impact efforts provided by the Contractor:
FOR VA USE
VA Engineering Action Approved Disapproved Reason for Disapproval:
Project Engineer/COR Signature Date
| Contractor Representative Name: |
| Date: |
| NamePolice: |
| Phone NumberPolice: |
| NameSafety: |
| Phone NumberSafety: |
| NameEngineer: |
| Phone NumberEngineer: |
| NameContracting: |
| Phone NumberContracting: |
| Project Number and Title: |
| Contract Number: |
| Location of Work: |
| Contractor Name: |
| Contractor Phone Number: |
| Contractors Representative: |
| Date_2: |
| Time: |
| Date_3: |
| Time_2: |
| Brief Description of Work Activities: |
| Utilities Affected electrical HVAC water medical gas fire supression etc Include panel equipment: |
| Areas impacted by shutdown Provide as much detail as possible Building Room numbers Departments etc: |
| Mitigation of impact efforts provided by the Contractor: |
| Reason for Disapproval: |
| Date_4: |
| Disapproved: Off |
| Approved: Off |
| Text1: |
| Text2: |
| Text3: |
| Text4: |
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