ATTACHMENT F - SAFETY CHECKLIST.pdf
PDF 120 KB Posted
- Attached to
- Durable Medical Equipment Services
- Solicitation number
- 36C25626Q0301
About this file
This is a Safety Checklist template (Attachment F) used for equipment delivery to veterans through the VA/Prosthetics program. The form documents safety verification and infection control procedures that must be completed during equipment delivery to ensure veteran and caregiver safety.
The checklist contains six safety assessment items covering equipment operation compliance with manufacturer guidelines, electrical outlet safety verification, three-prong grounded adapter installation, electrical leakage inspection, discovery and identification of unsafe conditions, and reporting of any unsafe conditions to VA/Prosthetics. An additional infection control section verifies that the veteran or caregiver understands cleaning techniques for the provided equipment. The form includes a comments section for documenting additional instructions reviewed with the patient or caregiver, and requires signatures and dates from both the veteran/caregiver and delivery person to confirm completion of all safety protocols and instruction delivery.
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Text version
SAFETY CHECKLIST (ATTACHMENT F)
VETERAN NAME:
SAFETY CHECKLIST: YES NO NA
1. Was equipment operating in accordance with the ( ) ( ) ( ) manufacturer’s guidelines?
2. Were the electrical outlets to be used with the equipment ( ) ( ) ( ) checked for safety?
3. Was a three (3) prong grounded adapter provided/installed? ( ) ( ) ( )
4. Was the equipment properly checked for electrical leakage? ( ) ( ) ( )
5. Were unsafe conditions discovered/identified? ( ) ( ) ( )
6. Were unsafe conditions reported to the VA/Prosthetics? ( ) ( ) ( )
INFECTION CONTROL:
1. Does the veteran/caregiver know the cleaning techniques to ( ) ( ) ( ) be used for the equipment provided?
COMMENTS:
Any additional instructions reviewed with patient/caregiver:
VETERANS/CAREGIVER SIGNATURE DATE
DELIVERY PERSON’S SIGNATURE DATE
File details come from the government source that posted it. Updated .