Exhibit C Safety Checklist.docx
DOCX document 16 KB Posted
- Solicitation number
- 36C25625R0109
About this file
The file is a Safety Checklist (Exhibit 3) designed for durable home medical equipment (DME) delivery and installation. The checklist covers critical safety and infection control procedures, including equipment operation verification, electrical safety checks, and cleaning technique confirmation. It requires signatures from both the veteran/caregiver and delivery personnel, with checkboxes to document compliance with safety protocols such as manufacturer guidelines, electrical outlet safety, grounding, electrical leakage testing, and reporting of unsafe conditions.
This safety checklist is directly related to Solicitation Number 36C25625R0109, a Set-Aside Service-Disabled Veteran-Owned Small Business (SDVOSB) Request for Quote (RFQ) for Durable Home Medical Equipment Accessories Services at the Alexandria Veterans Health Care System. The solicitation seeks a firm-fixed price contract for DME/HME services, with technical questions due by 2:30 PM CDT on 06/25/2025 and offer submissions due by 2:30 PM on 06/27/2025. Offerors must be registered in SAM and certified through SBA's VetCert program, with services to be performed at the Alexandria VA HealthCare System in Pineville, Louisiana.
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Other files
| File | Type | Posted |
|---|---|---|
| S06 - 36C25625R0109 0001.pdf | ||
| 36C25625R0109 0001_1.docx | DOCX document | |
| Exhibit B Patient Rghts and Responsibilities.docx | DOCX document | |
| Attachment 2 QASP.pdf | ||
| Exhibit A Delivery Checklist.docx | DOCX document | |
| 36C25625R0109.pdf | ||
| 36C25625R0109_1.docx | DOCX document | |
| Attachment 1 PWS- Alexandria DME.pdf | ||
| Attachment 3 Conbined WDs 2015-5175 5183 5197 5209.pdf |
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Text version
SAFETY CHECKLIST (Exhibit 3)
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 .