ATTACHMENT 33 - Boiler Safety Device Interim Safety Measure Form.pdf
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- Solicitation number
- 36C24826R0090
About this file
This is a template form for documenting interim safety measures related to boiler safety devices in Veterans Health Administration (VHA) facilities. The Boiler Safety Device Interim Safety Measure Form (138-82) is designed to document deficiencies in boiler safety equipment that do not meet the functional and testing requirements outlined in VHA Directive 1810 and the VHA Boiler Plant Safety Device Testing Manual. The form captures essential information including the ISM number, effective date, specific safety device identification, a detailed description of the deficiency, and an assessment of associated risks such as potentially dangerous boiler operating conditions that could result in property loss and personnel injury.
The form establishes interim safety procedures that boiler plant personnel must follow to verify safe operating conditions until the deficiency is corrected. The interim measures include specific conditions and verification frequencies defined by facility personnel. The completed form requires multiple signatures from Unit Safety and Risk Officers (USRO), the Boiler Plant Supervisor, Chief Engineer, and Medical Center Director, ensuring approval and accountability across supervisory and safety leadership. Executed forms must be maintained in both the Boiler Plant and Engineering Office for documentation and compliance purposes.
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Text version
138-82
Boiler Safety Device Interim Safety Measure Form
Created By: John Q. Operator
ISM Number: XXXXXXXX
Status: Active/Inactive
Date Effective: X/X/XXXX
Safety Device: Device X
Description of Deficiency: Device X on boiler #X does not meet the functional and testing requirements of VHA Directive 1810 and the VHA Boiler Plant Safety Device Testing Manual.
Risk: Potentially dangerous boiler operating conditions that could result in property loss and personnel injury.
Impacted Personnel: Boiler Plant Operator Personnel and Supervision
Interim Safety Measure Description/Procedure: Boiler Plant Personnel will do X conditions at X frequency to verify safe operation conditions are present. May require detailed procedure; if so, reference procedure X.
Signatures required as indicated below. Completed form will be maintained in the Boiler Plant and Engineering Office.
USRO: ________________Date: ________ USRO: _________________ Date:__________
USRO: ________________Date: ________ USRO: _________________ Date:__________
USRO: ________________Date: ________ USRO: _________________ Date:__________
USRO: ________________Date: ________ USRO: _________________ Date:__________
Boiler Plant Supervisor: _________________________ Date: ____________________
Chief Engineer: _______________________________ Date: ____________________
Medical Center Director: ________________________ Date: ______________________
File details come from the government source that posted it. Updated .