Package 4 Attachments.pdf

For the best experience, open this PDF portfolio in

Acrobat X or Adobe Reader X, or later.

Get Adobe Reader Now!

http://www.adobe.com/go/reader

Attachment 6

VA Information and Information System

Security/Privacy Language

SECTION 01 00 00

GENERAL REQUIREMENTS

Attachment 6 With No Sensitive but Require Training- VA Information and Information System Security/Privacy

Language

VA INFORMATION AND INFORMATION SYSTEM SECURITY/PRIVACY LANGUAGE

VA INFORMATION CUSTODIAL LANGUAGE:

A. If VA determines that the contractor has violated any of the information confidentiality, privacy, and security provisions of the contract, it shall be sufficient grounds for VA to withhold payment to the contractor or third party or terminate the contract for default or terminate for cause under

Federal Acquisition Regulation (FAR) part 12.

SECURITY INCIDENT INVESTIGATION:

A. The term “security incident” means an event that has, or could have, resulted in unauthorized access to, loss or damage to VA assets, or sensitive information, or an action that breaches VA security procedures. The contractor/subcontractor shall immediately notify the COTR and simultaneously, the designated ISO and Privacy Officer for the contract of any known or suspected security/privacy incidents, or any unauthorized disclosure of sensitive information, including that contained in system(s) to which the contractor/subcontractor has access.

B. To the extent known by the contractor/subcontractor, the contractor/subcontractor’s notice to VA shall identify the information involved, the circumstances surrounding the incident (including to whom, how, when, and where the VA information or assets were placed at risk or compromised), and any other information that the contractor/subcontractor considers relevant.

C. With respect to unsecured protected health information, the business associate is deemed to have discovered a data breach when the business associate knew or should have known of a breach of such information. Upon discovery, the business associate must notify the covered entity of the breach. Notifications need to be made in accordance with the executed business associate agreement.

D. In instances of theft or break-in or other criminal activity, the contractor/subcontractor must concurrently report the incident to the appropriate law enforcement entity (or entities) of jurisdiction, including the VA OIG and Security and Law Enforcement. The contractor, its employees, and its subcontractors and their employees shall cooperate with VA and any law enforcement authority responsible for the investigation and prosecution of any possible criminal law violation(s) associated with any incident. The contractor/subcontractor shall cooperate with

Section 01 00 00, Revised May 2015 General Requirements – Attachment #6 Page 1

VA in any civil litigation to recover VA information, obtain monetary or other compensation from a third party for damages arising from any incident, or obtain injunctive relief against any third party arising from, or related to, the incident.

LIQUIDATED DAMAGES FOR DATA BREACH:

A. Consistent with the requirements of 38 U.S.C. §5725, a contract may require access to sensitive personal information. If so, the contractor is liable to VA for liquidated damages in the event of a data breach or privacy incident involving any SPI the contractor/subcontractor processes or maintains under this contract.

B. The contractor/subcontractor shall provide notice to VA of a “security incident” as set forth in the

Security Incident Investigation section above. Upon such notification, VA must secure from a non-Department entity or the VA Office of Inspector General an independent risk analysis of the data breach to determine the level of risk associated with the data breach for the potential misuse of any sensitive personal information involved in the data breach. The term 'data breach' means the loss, theft, or other unauthorized access, or any access other than that incidental to the scope of employment, to data containing sensitive personal information, in electronic or printed form, that results in the potential compromise of the confidentiality or integrity of the data. Contractor shall fully cooperate with the entity performing the risk analysis. Failure to cooperate may be deemed a material breach and grounds for contract termination.

SECURITY CONTROLS COMPLIANCE TESTING :

On a periodic basis, VA, including the Office of Inspector General, reserves the right to evaluate any or all of the security controls and privacy practices implemented by the contractor under the clauses contained within the contract. With 10 working-day’s notice, at the request of the government, the contractor must fully cooperate and assist in a government-sponsored security controls assessment at each location wherein VA information is processed or stored, or information systems are developed, operated, maintained, or used on behalf of VA, including those initiated by the Office of Inspector

General. The government may conduct a security control assessment on shorter notice (to include unannounced assessments) as determined by VA in the event of a security incident or at any other time.

TRAINING:

A. All contractor employees and subcontractor employees requiring access to VA information and

VA information systems shall complete VA Privacy and Information Security Awareness and

Rules of Behavior Training.

1. Sign and acknowledge (either manually or electronically) understanding of and responsibilities for compliance with the Rules of Behavior.

General Requirements – Attachment #6 Page 2

B. The contractor shall provide to the contracting officer and/or the COTR a copy of the training certificates and certification of signing the Rules of Behavior for each applicable employee within

1 week of the initiation of the contract and annually thereafter, as required.

C. Failure to complete the mandatory annual training and sign the Rules of Behavior annually, within the timeframe required, is grounds for suspension or termination of all physical or electronic access privileges and removal from work on the contract until such time as the training and documents are complete.

The Certification and Accreditation (C&A) requirements do not apply and a Security Accreditation

Package is not required for this SOW.

General Requirements – Attachment #6 Page 3

Contract Information:

Reset:

Print:

Package 4 Attachments for Incorporate/Integrate Double-Ended Switchgear for Building 38 Project 673-20-104; RFP 36C24821R0150

VA 01 00 00 General Requirements - Appendix A VA 01 00 00 General Requirements - Appendix B VA 01 00 00 General Requirements - Appendix C VA 01 00 00 General Requirements - Appendix D VA 01 00 00 General Requirements - Attachment 1a and 1b VA 01 00 00 General Requirements - Attachment 2 VA 01 00 00 General Requirements - Attachment 3 VA 01 00 00 General Requirements - Attachment 4 VA 01 00 00 General Requirements - Attachment 5a and 5b VA 01 00 00 General Requirements - Attachment 6

Appendix A

Approved OSHA Training Providers List

Appendix A

Approved OSHA Training Providers List

Current List of Approved Outreach On-line Training Websites:

Construction 10 hour

A. Bright Brains / AdvanceOnline - www.advanceonline.com and hosted through:

1. Region X OSHA Training Institute Education Center: www.regionxoti.org

2. AGC: http://agc.advanceonline.com

3. JJ Keller: www.keller-itc.com

B. ClickSafety - www.clicksafety.com and hosted through:

1. Keene State College: www.keene.edu/conted/osha.cfm

C. 360Training - www.oshacampus.com and hosted through:

1. Eastern Kentucky University - http://eku.360training.com

2. Metropolitan Community Colleges - http://mcc.360training.com

3. Red Rocks Community College - http://rrcc.360training.com

4. WESTEC OSHA ED Center - http://westec.360training.com

Construction 30 hour

A. Turner Construction - https://www.turnerknowledge.com/turner/livelink.exe?func=login.channelpartner

B. ClickSafety - www.clicksafety.com and hosted through:

1. Keene State College: www.keene.edu/conted/osha.cfm

General Requirements – Appendix A Page 1 http://www.advanceonline.com/ http://www.regionxoti.org/ http://agc.advanceonline.com/ http://www.keller-itc.com/ http://www.clicksafety.com/ http://www.keene.edu/conted/osha.cfm http://eku.360training.com/ http://mcc.360training.com/ http://rrcc.360training.com/ http://westec.360training.com/ https://www.turnerknowledge.com/turner/livelink.exe?func=login.channelpartner http://www.clicksafety.com/ http://www.keene.edu/conted/osha.cfm

Contract Information:

Reset - #5A:

Print - #5A:

Appendix B

VA Adopted Codes

Appendix B

VA Adopted Codes

GENERAL: VA has adopted the latest editions of the following codes and standards as a minimum for all projects performed in the modernization, alteration, addition, or improvement of its real property and the construction of new structures. VA design Manuals and Master Specifications specify other codes and standards that VA follows on its projects:

A. VA Directives, Design Manuals, Master Specifications, VA National CAD Standard Application

Guide, and other Guidance on the Technical Information Library (TIL)

(http://www.cfm.va.gov/til/)

B. International Building Code (IBC), including International Mechanical and Plumbing Codes

C. NFPA 101, Life Safety Code (see NOTES below)

D. NFPA National Fire Codes, with the exception of NFPA 5000 and NFPA 900

E. Occupational, Safety and Health Administration (OSHA) Standards

F. VA Seismic Design Requirements, H-18-8

G. NFPA 70, National Electrical Code (NEC)

H. National Standard Plumbing Code (NSPC)

I. American Society of Mechanical Engineers (ASME) Safety Code for Elevators and Escalators, (A17.1)

J. ASME Boiler and Pressure Vessel Codes

K. ASME Code for Pressure Piping

L. Architectural Barriers Act Accessibility Standard (ABAAS) including VA Supplement, Barrier

Free Design and (ABA)

M. Building Code Requirements for Reinforced Concrete, American Concrete Institute and

Commentary (ACI 318)

N. Manual of Steel Construction, Load and Resistance Factor Design Specifications for Structural

Steel Buildings, American Institute of Steel Construction (AISC)

O. Energy policy Act of 2005 (EPAct)

P. American Society of Heating and Refrigeration Engineers (ASHRAE) 90.1, Energy Standards for

Buildings Except Low-Rise Residential Buildings

Q. Federal Leadership in High Performance and Sustainable Buildings: Memorandum of

Understanding (MOU)

General Requirements – Appendix B Page 1 http://www.cfm.va.gov/til/

R. Executive Order 13423: Strengthening Federal Environmental, Energy, and Transportation

Management

S. Executive Order 13514, Federal Leadership in Environmental, Energy, and Economic

Performance

T. The Provisions for Construction and Safety Signs. Stated in the General Requirements, Section

01 00 00, of the VA Construction Specifications

U. America Society of Heating and Refrigeration Engineers (ASHRAE), Ventilation for Acceptable

Indoor Air Quality – ASHRAE Standard 62.1

V. Safety Standard for Refrigeration Systems – ASHRAE Standard 15

Local Codes: As an agency of the federal government, VA is not subject to local imposition of code enforcement procedures (drawing reviews, building permits, inspections, fees, etc.). VA must function as the Authority Having Jurisdiction (AHJ) and thus has the responsibility to guard public health and safety through enforcing its adopted codes. However, local authorities may be notified about planned projects and given opportunity to review drawings provided that VA does not pay for review or inspection fees.

NOTES:

1. NFPA 101 primarily addresses life safety and fire protection features while the IBC addresses a wide range of considerations, including, but not limited to, structural strength, stability, sanitation, adequate light and ventilation, and energy conservation. VA buildings must meet the requirements of NFPA 101 and documents referenced by NFPA 101 in order to comply with the accreditation requirements of The Joint Commission for the Accreditation of Hospitals.

Therefore, designs shall comply with the requirements of the latest edition of NFPA 101 and documents referenced therein. Design features not addressed by NFPA 101 or documents referenced therein shall comply with the requirements of the latest edition of the IBC or as otherwise addressed above in this Program Guide. For design features that are addressed by both the IBC as well as NFPA 101 or a document referenced by NFPA 101, the requirements of NFPA

101 or the document referenced by NFPA 101 shall be used exclusively (this applies even if the

IBC requirements are different).

2. Conflicts between Nationally Recognized Codes and Standards and VA Requirements:

Should a conflict exist between VA requirements and VA adopted nationally recognized codes and standards, the conflict shall be brought to the attention of VA. The resolution of the conflict shall be made by the authority having jurisdiction for VA to ensure a consistency system wide.

General Requirements – Appendix B Page 2

Contract Information:

Reset:

Print:

Appendix C

Facilities Management Service‐Alerts

Appendix C

Proper Procedures and Forms for all Access Closures, Utility Shutdowns and Live Electrical Work Request

GENERAL NARRATIVE OF DOCUMENTATION REQUIREMENTS FOR

PLANNED UTILITY SHUTDOWNS

General: All of the following types of work will be documented by the requesting party (contractor or in-house maintenance person) in a file folder fitted with two-hole prong paper fasteners.

Fasteners will be attached to the tops of each cover of the file folder. This narrative should be used in conjunction with the Utility Shutdown Flow Chart for a clear understanding of the shutdown process.

1. Planned Utility Shutdown:

In accordance with Hospital Policy Memorandum (HPM) 138-23, June 2007, a request for utility shutdown must be presented to the Chief, Facilities Management Service (FMS), for evaluation and action to determine whether the shutdown will be classified as routine or major.

A. A Draft Utility Shutdown Notice is initiated by the requesting party and upon completion will be stapled to the outside front-cover of the file folder.

B. The Planned Utility Interruption/ Checklist will be attached to the inside front-cover using the two-hole prong fastener.

C. The Work Plan / Peer Review form (attachment #5) is initiated and attached to the inside back-cover using the two-hole prong fastener.

D. All Supporting Documents will be attached to the inside back-cover of the file folder in reverse chronological order (most recent on top). These documents include, but are not limited to, (1) any required permits (enclosed space, above ceiling, etc.) and approvals, (2) drawings / sketches of work, (3) meeting minutes, (4) coordination with affected services, (5) Mitigation

Plan, (6) Contingency Plan, (7) shutdown procedures, and (8) start-up procedures, or as required by the Approving Official (Chief, FMS).

2. Live Electrical Work:

In accordance with VHA Directive 2006–056, any energized electrical work plan must have the prior knowledge and approval of the Medical Center Director (Exception – The Chief, FMS may approve energized electrical work plans for Branch Circuits, from the final overcurrent protecting devices to the outlets, that do not serve the critical patient care areas, such as Operating Rooms, Critical Care, Intensive Care, Dialysis Units, Isolation Rooms, Catheterization Laboratories, Emergency Rooms, or

Supply, Processing, and Distribution (SPD) rooms).

General Requirements – Appendix C Page 1

A. The Request to Perform Live Electrical Work (memo to the Hospital Director) is initiated and upon approval will be attached to the inside back-cover using the two-hole prong fastener.

B. The Work Plan / Peer Review form (attachment #5) is initiated and attached to the inside

C. All Supporting Documents will be attached to the inside back-cover of the file folder in sketches of work, (3) meeting minutes, and (4) coordination with affected services.

3. Hot Work (Burn):

Facilities Management Service Standard Operating Procedures No. 138-05, August 2009, defines Hot

Work as operations which include “… cutting, welding, brazing, silver soldering and other processes that utilize an open flame or arc.” Please note that although Live Electrical Work is sometimes referred to in the trade as Hot Work, it is not (within the context of this document) since under normal working conditions it will not result in an open flame or arc.

A. The Hot Work (Burn) Permit is initiated and consists of two documents – the Notification of

Hot Work Operations by Contractor Personnel (Burn Permit) and the Hot Work Fire Safety

Check List for Operations Area Inspection (Attachments 2 & 3). Upon approval it will be posted at the job site until all work has been completed. After completion of work, the documents will be attached to the inside back-cover of the file folder.

B. The Work Plan / Peer Review form (attachment #5) is initiated and attached to the inside

C. All Supporting Documents will be attached to the inside back-cover of the file folder in sketches of work, (3) meeting minutes, and (4) coordination with affected services. The following flowchart is based on the Planned Utility Interruption Checklist included within

Appendix C.

4. Planned Access Closure Request:

A. A request for an access closure must be presented to the Chief, Facilities Management Service

(FMS), for evaluation and action to determine whether the closure will be classified as routine or major.

B. A Draft Closure Notice is initiated by the requesting party and upon completion will be stapled to the outside front-cover of the file folder.

C. The Planned Utility Interruption/Closure Checklist will be attached to the inside front-cover using the two-hole prong fastener.

General Requirements – Appendix C Page 2

D. The Work Plan and Peer Review form (attachment #5) is initiated and attached to the inside

E. All Supporting Documents will be attached to the inside back-cover of the file folder in sketches of work, (3) meeting minutes, (4) coordination with affected services, (5) Mitigation

Plan, (6) Contingency Plan, (7) shutdown procedures, and (8) start-up procedures, or as required by the Approving Official (Chief, FMS).

General Requirements – Appendix C Page 3

PLANNED UTILITY INTERRUPTION CHECKLIST

Project Name: Project #

COTR Name: Phone #:

1. Utility Shutdown Request

# Item POC Comments 1.a. Draft Utility Shutdown Notice COTR 1.b Work Plan, draft Timeline & Peer review Contractor /

COTR

1.c Other Work Plans (Piggyback work) M&O /

1.d Utility prints marked with isolation points for valves, equipment

COTR /

M&O

1.e Identify affected areas / services COTR /

1.f Identify duration of shutdown Contractor /

1.g Draft mitigation plan COTR /

2. Planning the Shutdown

2.a. Peer Review complete COTR 2.b Chief FMS determines “Routine” or “Major” shutdown Chief FMS

2.c Coordination meetings as applicable 2.d Coordinate with affected areas & services* COTR /

2.e Prepare utility shutdown and start-up procedures

M&O Shops

2.f Verify & update prints COTR 2.g Finalize Utility Mitigation Plan M&O 2.h Identify Contingency Plan COTR /

2.i Publish Utility Shutdown Notice COTR

*Include respiratory therapy on all AOV-related system modifications.

3. Preparation

3.a. Tag and mark field verified equipment and locations of valves / breakers, switches, etc that disrupt utilities & hospital services*

3.b Stage work materials, pre-fabricated parts, etc.

24 hours before work is to begin. The COTR is to verify that all materials and tools are present.

Contractor

General Requirements – Appendix C Page 4

3.c Stage mitigation supplies & services M&O 3.d Shutdown folder to CEP, contents include (as applicable):

• Final Shutdown Notice

• Work Plan with Peer review & Timeline

• Mitigation Plan

• POC Lists with contact information

• Shutdown and Start up procedures

CEP

Supervisor

*Includes all sources of stored energy and services such as medical gasses.

4. Execution

4.a. COTR informs CEP to initiate shutdown COTR 4.b CEP initiates shutdown*; equipment is LOTO as planned

4.c Monitor shutdown and informs all parties when utility / service is secure

4.d Tracks progress via the Work Plan Timeline CEP / COTR 4.e Notifies CEP when work is complete COTR 4.f Initiates start up procedures to return the utility to service

4.g Notifies AOD when facility returns to safe state CEP

*Contact Respiratory Therapy POC whenever AOV-related items are affected.

5. Recovery

5.a Mitigation measures removed; report completion to CEP CEP / Shops

5.b Update Drawings COTR 5.c File Shutdown Folder Chief, FMS

Note: Be sure to include the following on this side of 2-Prong Folder. Some elements may be omitted.

1. Notes from Shutdown Meetings / Coordination

2. Mitigation Plan

3. Contingency Plan

4. Shutdown procedures

5. Work Plan / Peer Review

6. Start-up procedures

General Requirements – Appendix C Page 5

Distributed:

AREA(S)

AFFECTED:

TIME /

DURATION:

DATE:

ESTIMATED TIME FRAME:

HOW THIS AFFECTS YOU:

REASON FOR SHUTDOWN:

FMS CONTACT PERSON: , COTR

@ ext. , or Cell

If you have any questions or problems with this date, please notify the contact person(s) above by the close of business one day from the date of this publication. After that date, the closure will proceed as described above. Supervisors, please share with all staff.

Chief, Facilities Management Service

PLEASE SHARE WITH ALL STAFF

General Requirements – Appendix C Page 6

ENERGIZED (LIVE) ELECTRICAL WORK DIRECTOR MEMO

Date:

From: Facilities Management Service (138)

Subject: Request to Perform Live Electrical Work for the Project

To: Director (00)

1. In accordance with VHA Directive 2006-056 an energized electrical work plan must have the prior knowledge, and approval of the Medical Center Director.

Description of the work being performed, and the circuits impacted by this work:

2. The start date for this work is . The estimated duration for this work is hours.

3. Any questions or concerns please call , Project Engineer / COTR, at extension , VA Cell Phone , or e-mail:

Approve Disapprove

, Director (00) Date:

Enclosure:

General Requirements – Appendix C Page 7

HOT TAP WORK PERMIT - EQUIPMENT IN SERVICE (Page 1 of 3) Note: Separate request required for each individual hot tap.

Part I: TO BE COMPLETED BY THE REQUESTER:

Job/Work Order Number:

(1) Description of piping/equipment/job location:

(2) Description of work to be done:

(3) Justification of why the piping/equipment cannot be de-energized through explanation of continuity of service is essential & shutdown impractical (Note: Inconvenience is not a factor):

Requester/Title: Date:

Part II: TO BE COMPLETED BY THE QUALIFIED PERSONS DOING THE WORK:

YES NO

(1) Have personnel executing the “Hot Tap” procedure provided documentation of the necessary level of training to meet responsibilities associated with the procedure.

(2) Competent Person oversight is available and will be present during the hot tapping.

(3) Welding Required

(4) Hot Work permit was obtained and includes a specific Hot Tapping Welding Safety

Task Review (API-2201, Appendix C)

(5) Emergency Action Plan developed (i.e.API-2201, Appendix D)

(6) Necessary personal protective equipment to safely perform the assigned task (FR Clothing, Welding

Helmet, Gloves, etc…)

(7) Means employed to restrict the access of unqualified persons from the work area:

(8) Evidence of completion of a Job Briefing including discussion of any job-related hazards:

(9) Multi-Gas Meter is available, calibrated, and will be used for monitoring

(10) Do you agree the described work can be done safely? (If no return to requester)

Contractor/ VA Operation Supervisor(s):

COTR/VA Project Engineer:

General Requirements – Appendix C Page 8

HOT TAP WORK PERMIT - EQUIPMENT IN SERVICE (Page 2 of 3) Part III: RECOMMENDATION(S) TO PERFORM THE WORK WHILE EQUIPMENT IS IN

SERVICE:

Facility Safety Officer:

Chief, Facilities Management Service:

Part IV: APPROVAL TO PERFORM THE WORK WHILE EQUIPMENT IS IN SERVICE:

Medical Center Director:

TO BE FILLED OUT BY THE REQUESTER

TYPE OF PROPOSED INSTALLATION:

HEADER OR VESSEL INFORMATION

LINE SIZE (in.): METALLURGY:

OPERATING PRESSURE: PSIG TEMPERATURE:

PROCESS DESCRIPTION:

BRANCH CONNECTION INFORMATION

LINE SIZE (in.): FLANGE RATING: PSI

OPERATING PRESSURE: PSIG METALLURGY:

INITIATOR:

Provide location sketch of the proposed hot tap. The hot tap location must have scaffolding (where required for access), insulation must be removed and the equipment must be marked for the exact hot tap location prior to notifying Pressure Equipment Inspection.

General Requirements – Appendix C Page 9

HOT TAP WORK PERMIT - EQUIPMENT IN SERVICE (Page 3 of 3) TO BE FILLED OUT BY THE CONTRACTOR (COMPETENT PERSON) or VA PROJECT ENGINEER

AND PRESSURE EQUIPMENT ENGINEER (QUALIFIED PERSON)

WALL THICKNESS AT HOT TAP LOCATION: (in.)

DETERMINED BY:

WELD DETAIL NUMBER:

1. PROCEDURE: X-RAY:

2. PROCEDURE: X-RAY:

3. PROCEDURE: X-RAY:

INSPECTOR:

TESTS REQUIRED:

(A) NOZZLE: PSIG MEDIUM:

(B) REINFORCING PAD: PSIG MEDIUM:

(C) BLOCK VALVE: HYDROSTATIC SEAT EACH SIDE AT: PSIG

AREA INSPECTOR:

PRESSURE EQUIPMENT ENGINEER:

TO BE FILLED OUT BY THE CONTRACTOR PERFORMING THE HOT TAP

HOT TAP MACHINE:

MAKE:

MACHINE RATING: PSIG @: F

MODEL:

PRESSURE TESTED @ PSIG

SERIAL NO.:

BY: DATE:

CONTRACTOR REPRESENTATIVE:

General Requirements – Appendix C Page 10

Distributed:

AREA(S)

AFFECTED:

TIME /

DURATION:

DATE: ESTIMATED TIME FRAME:

HOW THIS AFFECTS YOU:

REASON FOR SHUTDOWN:

FMS CONTACT PERSON: , COTR

@ ext. , or Cell

If you have any questions or problems with this date, please notify the contact person(s) above by the close of business one day from the date of this publication. After that date, the closure will proceed as described above. Supervisors, please share with all staff.

PLEASE SHARE WITH ALL STAFF

General Requirements – Appendix C Page 6

Distributed:

CommentsCOTR:

CommentsContractor COTR:

CommentsMO COTR:

CommentsCOTR MO:

CommentsCOTR MO_2:

CommentsContractor COTR_2:

CommentsCOTR MO_3:

CommentsCOTR_2:

CommentsChief FMS:

CommentsCoordination meetings as applicable:

CommentsCOTR MO_4:

CommentsMO Shops:

CommentsCOTR_3:

CommentsMO:

CommentsCOTR MO_5:

CommentsCOTR_4:

CommentsMO_2:

CommentsContractor:

MO:

CEP Supervisor:

CommentsCOTR_5:

CommentsCEP:

CommentsCEP_2:

CommentsCEP COTR:

CommentsCOTR_6:

CommentsCEP_3:

CommentsCEP_4:

CommentsCEP Shops:

CommentsCOTR_7:

CommentsChief FMS_2:

Contract Information:

Memo Date:

Description of Work:

Start Date of Work:

Hours:

Project Engineer or COTR Name:

COTR Phone Extension1:

COTR Cell Phone #1:

COTR Email:

Name of FMS Chief:

Group60: Off

Medical Center Director Name:

Director Date:

Enclosures:

Job/Work Order #:

Description of Location:

Description of Work1:

Justification:

Requester Name:

Request Date:

Group61: Off

Group62: Off

Group63: Off

Group64: Off

Group65: Off

PPE:

Means Employed to Restrict Access:

Evidence of Completion:

Group66: Off

Group67: Off

Contractor/VA Operation Supervisor:

Supervisor Date:

COTR Name2:

COTR Date2:

FMS Chief Date3:

Director Date3:

Safety Date3:

Type of Installation:

Line Size:

Pressure:

Temperature:

Process Description:

Line Size2:

Flange Rating:

Pressure2:

Metallurgy:

Metallurgy2:

Initiator Name:

Initiator Date:

Wall Thickness:

Determined By Name:

Weld Detail #:

Procedure:

X-Ray:

Procedure2:

Procedure3:

X-Ray2:

X-Ray3:

Inspector Name:

Test Required:

Nozzle:

Reinforcing Pad:

Medium2:

Block Valve:

Medium:

Determined Date:

Area Inspector:

Hot Tap Machine:

Make:

Machine Rating:

Rating Temperature:

Model:

Pressure tested:

Pressure Engineer:

Submitted By:

Submitted by Date:

Contractor Rep Date:

Contractor Representative:

COTR Name5:

Project #5:

Project Name5:

COTR Phone #5:

Reset:

Print:

DATE:

ESTIMATED TIME FRAME:

HOW THIS AFFECTS YOU:

REASON FOR SHUTDOWN:

Alert Title:

Areas Affected:

FMS POC:

Phone Extension:

Cell Phone #:

Appendix D

Safety and Infection Control Guide

Appendix D

Safety and Infection Control Guide

Required to be Posted on the Construction Site This Safety and Infection Control Guide is for informational purposes only and is not meant to be used in place of the contract.

General Information and Telephone Numbers:

• CEP ext. 7080

• Police ext. 7554

• Safety Office ext. 7292

• Medical Emergency (Non-Life Threatening) Dial 123

• Medical Emergency (Life Threatening) VA ED / Dial 123

Fire Safety:

• Contractors shall provide worksite Fire Extinguishers and are required to perform and document monthly maintenance.

• All Contractors’ staff shall be aware exit locations in and around the worksite and keep them clear.

• If an alarm is activated in the construction area, a member of the construction crew shall be available to advise VA staff on the cause of the alarm (if known) and dial the CEP.

• Permits are required to perform “Hot Work Operations” including cutting, welding, brazing or silver soldering, or any process that utilizes an open flame.

Safety:

• Access to emergency services (fire, police and other emergency forces) shall be free and unobstructed.

• Temporary construction partitions shall be smoke tight and built of noncombustible or limited combustible materials.

• All Lock out / Tag out needed on utilities or equipment in the facility shall go through the COTR and VA Maintenance & Operations Supervisor.

• All penetrations made by Contractors during construction / renovation activities shall be sealed (at least temporarily) at the end of the work shift.

• Smoking is permitted only in designated areas, and NOT within the Construction site.

General Requirements – Appendix D Page 1

The following procedure is for reporting a fire at the JAHVH Facility:

FIRE SAFETY FOR CONTRACTORS

(SEGURIDAD CONTRA INCENDIOS PARA CONTRATISTAS)

CODE RED (FIRE)

CODIGO ROJO (FUEGO)

R – Rescue (Rescatar)

A – Alarm (Activar la Alarma)

Pull the nearest pull station. (Activar la alarma contra incendios mas cercana.)

Call 1-2-3 and inform the operator of location. (Marcar en el teléfono el numero 1-2-3 para informar a la operadora la localización del fuego.)

C – Contain (Close the door / Isolate the area of fire) (Contener) (Cerrar las puertas / Aislar el área del fuego)

E – Extinguish / Evacuate (Extinguir / Desalojar)

Privacy:

• Patient information found within a construction site should be turned in to the Nurse Manager or

COTR.

Security:

• ID Badges must be worn at all times while on duty.

• Parking is allowed in designated areas only.

General Requirements – Appendix D Page 2 http://en.wikipedia.org/wiki/Image:2099SimplexFireLever.jpg

Infection Control Orientation for Construction Workers

The dirt and dust that are part of construction activities contain hidden infectious hazards. It is not “just dust”. One such hazard is fungal organisms such as Aspergillus. Aspergillus may be found in decaying leaves and compost, plaster and drywall, standing water, and settled dust. These organisms usually do not cause problems in healthy people, but can cause problems in a hospital with sick patients, especially those with lung problems, or in those with poor immunity, such as transplant or cancer patients. Therefore, it is critical that you do your part to keep everyone in the hospital safe and healthy as possible. We, in turn, will make conditions as safe as possible for you.

1. Medical Waste:

a. Hospital staff will remove any medical waste, including sharp object containers (for used needles and syringes), from construction areas prior to the start of projects.

b. Please notify your supervisor and the COTR or Resident Engineer immediately if you (contract workers) find any needles, syringes, sharp medical objects or red bag waste left in the construction area.

2. Barrier Walls:

a. Construction areas must be kept separate from patient care areas by barriers that keep the dust and dirt inside the worksite.

b. Walls must provide a complete seal of the construction area from adjacent areas, 1.8.E.2 (walls may be rigid or 6 mil thick plastic)minimum .

c. Any gaps or breaks in barriers must be repaired immediately.

3. Environmental Control:

a. The construction zone and adjacent entry areas shall be maintained daily by the Contractor in a clean and sanitary manner.

b. Vacuum dirt and dust routinely inside the work area. This will minimize dirt tracking on shoes and reduce the dust generation inside the work area. (Sweeping creates more dust in the air).

c. Debris shall not be hauled through patient care areas unless approved by Infection Control and the COTR or Resident Engineer.

d. Demolition debris must be removed in carts with a tightly fitted cover.

e. Do not overfill carts so that cover will not fit tightly.

f. If 6 mil plastic minimum is used as cover, no sharp objects shall be allowed to cut through the plastic.

g. Wipe down the exterior of the carts with a damp rag to remove dust before taking it through the hospital.

h. Debris removal will follow specified traffic patterns and elevator usage.

General Requirements – Appendix D Page 3

i. Sticky or walk - off mats (minimum of 24 x 36 inches) shall be placed immediately outside the construction area and are changed regularly (i.e., whenever they no longer remove dirt from feet).

j. Contractor must ensure that their staff mop any dirt / dust tracking which occurs outside the construction barrier by their workers with a damp mop.

k. There shall be no standing water left in the construction area. This includes water in equipment drip pans and any open containers within the construction area.

l. All accidental spills must be cleaned up and dried within 12 hours.

m. Remove and dispose of porous materials that remain damp for more than 48 hours.

n. Optimally, construction-zone air will be exhausted directly to the outside with no potential for re-circulation. If an existing direct exhaust system cannot be located and a tie into re-circulated air system is necessary, a pre-filter and high efficiency filter (95%) will be used prior to exhaust to prevent contamination of the duct. The filters will be changed routinely so that operational performance of unit is maintained.

o. Negative air pressure must be maintained within the construction area for all projects that generate a moderate or high level of dust and are adjacent to any patient care or treatment area.

p. Contractors working in a sterile or invasive procedure area of the hospital will be provided with a disposable coverall, head cover, and shoe covers that must be worn upon entry and removed after exiting that area.

q. Tools and equipment must be damp-wiped prior to entry and exit from sterile and invasive procedure areas.

r. All equipment, tools, material, etc., transported through occupied patient areas shall be made free from dust and moisture by vacuuming and wipe down.

s. Water mist work surface to control dust when cutting or drilling.

t. Seal unused doors with duct tape.

u. Block off and seal air vents in construction area to prevent duct contamination.

v. Seal holes, pipes, conduits and punctures appropriately.

w. If demolition chutes are used, they must be sealed when not in use. The chute and damper should be sprayed with water, as necessary, to maintain dust control.

x. Control, collection and disposal must be provided for any drain liquid or sludge found when demolishing plumbing.

y. During outside excavation work, exterior window seals may be required to reduce the amount of outside dust entering the building.

4. Worksite Access Control:

a. Use designated entry and exit procedures.

b. Keep all hospital hallways free of debris and dirt.

General Requirements – Appendix D Page 4

c. No unauthorized personnel should be allowed to enter the construction areas.

d. Use designated elevators only.

5. Workers:

a. Clothing and shoes must be free of loose soil and debris when exiting the work area.

b. Use personal protective equipment (masks, face shields, etc.) as indicated for the task at hand.

c. Hand washing is the best method of reducing the transmission of infection. Always wash your hands with soap and water after visiting the restroom, before eating or smoking, and when leaving the construction site.

Please feel free to call the Infection Control Section at:

(813) 972-2000 extensions 4953 or 6953

Pagers 201-1764 or 201-1228

General Requirements – Appendix D Page 5

Contract Information:

Reset:

Print:

Attachments 1a & 1b

Fire Protection Notifications

ATTACHMENT #1 - A

NOTIFICATION OF IMPAIRED FIRE PROTECTION BY CONTRACTOR PERSONNEL

PROJECT No. & TITLE:

NAME OF FACILITY:

NOTIFIED BY:

TITLE:

COMPANY:

NATURE OF IMPAIRMENT:

PRECAUTIONS TO BE TAKEN:

CLOSED VALVE #: BLDG. #: ROOM #:

CONTROLLING:

START DATE: Su M T W Th F Sa @ TIME:

END DATE: Su M T W Th F Sa @ TIME:

JUSTIFICATION:

COTR CONTACTED: DATE/TIME

EXT: or CELL:

SAFETY OFFICER CONTACTED (EXT. 7598)

EGCC OPERATOR/CEP CONTACTED (EXT. 7080)

FIRE DEPARTMENT CONTACTED (813- 971-3636)

RSFPE CONTACTED ( )

General Requirements – Attachment #1 - A Page 1

ATTACHMENT #1 - B

NOTIFICATION OF RESTORED FIRE PROTECTION BY CONTRACTOR PERSONNEL

TITLE:

COMPANY:

NATURE OF IMPAIRMENT:

FULL PROTECTION RESTORED, EXCEPT:

OPENED VALVE #: BLDG. #: ROOM #:

CONTROLLING:

DATE: Su M T W Th F Sa @ TIME:

REASON FOR PARTIAL RESTORATION:

COTR CONTACTED: DATE/TIME

EXT: or CELL:

SAFETY OFFICER CONTACTED (EXT. 7598)

EGCC OPERATOR/CEP CONTACTED (EXT. 7080)

FIRE DEPARTMENT CONTACTED (813- 971-3636)

RSFPE CONTACTED ( )

General Requirements – Attachment #1 - B Page 1

DATETIMESAFETY OFFICER CONTACTED EXT 7598:

DATETIMEEGCC OPERATORCEP CONTACTED EXT 7080:

DATETIMEFIRE DEPARTMENT CONTACTED 8139713636:

DATETIMERSFPE CONTACTED:

DATETIMESAFETY OFFICER CONTACTED EXT 7598_2:

DATETIMEEGCC OPERATORCEP CONTACTED EXT 7080_2:

DATETIMEFIRE DEPARTMENT CONTACTED 8139713636_2:

DATETIMERSFPE CONTACTED_2:

Contract Information:

DATETIMECOTR CONTACTED:

DATETIMECOTR CONTACTED_2:

End Time - #1A:

Group18: Off

Group19: Off

Project # and Title - #1A:

Name of Facility - #1A:

Notified By - #1A:

Title - #1A:

Company - #1A:

Nature of Impairment - #1A:

Closed Valve - #1A:

BLDG # - #1A:

Room # - #1A:

Controlling - #1A:

Justification - #1A:

COTR Name - #1A:

COTR Phone Ext - #1A:

COTR Cell # - #1A:

RSFPE # - #1A:

Precautions Taken - #1A:

Precautions Taken - #1B:

Justification - #1B:

Start Time - #1A:

Start Time - #1B:

Group20: Off

Reset:

Print:

Attachment 2

Notification of Hot Work Operations by

Contractor Personnel (Burn Permit)

ATTACHMENT #2

NOTIFICATION OF HOT WORK OPERATIONS

BY CONTRACTOR PERSONNEL

(BURN PERMIT)

BUILDING # & NAME:

FLOORS:

ON DATE: Sn M T W Th F St WORK TIME:

WORK TO BE DONE:

SPECIAL PRECAUTIONS:

NAME OF FIRE WATCH PERSON IF APPLICABLE:

COMMENTS:

General Requirements – Attachment #2 Page 1

NOTIFIERS SIGNATURE & DATE:

TITLE & PHONE No.:

CONTRACTOR:

APPROVED APPROVED WITH COMMENT DISAPPROVED

COTR NAME:

COTR SIGNATURE & DATE:

SAFETY STAFF MEMBER:

SAFETY SIGNATURE & DATE:

General Requirements – Attachment #2 Page 2

Project # and Title:

Name of Facility:

Building # and Name:

Floors:

Work Time:

Check Box23: Off

Check Box24: Off

Check Box25: Off

Check Box26: Off

Check Box27: Off

Check Box28: Off

Check Box29: Off

Work To Be Done:

Special Precautions:

Name of Fire Watch Person:

Comments:

Notified By:

Title and Phone #:

Contractor:

Group38: Off

COTR Name:

Safety Name:

Contract Information:

Reset:

Print:

Attachment 3

Fire Safety Inspection Checklist for Hot Work

Operations Area

ATTACHMENT #3

FIRE SAFETY INSPECTION CHECKLIST FOR HOT WORK OPERATIONS AREA

Floor swept clean of combustibles.

Floors wet down, covered with damp sand, metal or other shields.

Combustibles material or flammable liquids removed from area, whenever possible.

Combustibles and flammable liquids protected with covers, guards, or metal shields.

All wall and floor openings covered.

Covers suspended beneath work to collect sparks.

WORK BEING DONE ON WALLS OR CEILINGS

Ensure wall construction is noncombustible and is without combustible covering.

Move combustibles away from opposite side of wall.

WORK BEING DONE ON ENCLOSED EQUIPMENT-(TANKS, DUCTS, ETC.)

Remove all combustibles from enclosures.

Purge of flammable vapors. Ensure continuous purge so no vapors accumulate during work.

FIRE WATCH

To be provided during and until 30 minutes after operation.

Provide a 10-pound dry chemical or halon extinguisher and small hose.

Workers trained in use of equipment and in sounding fire alarm.

FINAL CHECK-UP

Conducted 30 minutes after completion of any operation, unless fire watch is provided.

Notify Safety Office (extension 7292) when work is complete. (Contractors - notify COTR)

Notify Graphic Control Center (extension 7080), if any fire zones were by-passed

HOT WORK LOCATION:

NAME & PHONE No.:

General Requirements – Attachment #3 Page 1

Contract Information:

Project No:

and Title:

Date:

Check Box138: Off

Check Box139: Off

Check Box140: Off

Check Box142: Off

Check Box143: Off

Check Box145: Off

Check Box146: Off

Check Box147: Off

Check Box148: Off

Check Box149: Off

Check Box150: Off

Check Box151: Off

Check Box152: Off

Check Box153: Off

Check Box154: Off

Check Box155: Off

Hot Work Location:

Notifiers Name and Phone #:

Contractor Company Name:

Reset:

Print:

Attachment 4

Construction Fire Safety Checklist

ATTACHMENT #4

CONSTRUCTION FIRE SAFETY CHECK LIST

(For protection of VA property, patients, visitors and personnel)

PROJECT No. & Title:

A. FIRE EXTINGUISHERS (OSHA 1926.150[c])

(1) Extinguisher rated not less than 2A within 100 feet.

(2) Extinguisher rated not less than 10B within 50 feet, if flammable liquids or gases present.

B. IGNITION HAZARDS (OSHA 1926.1511[a])

(1) Internal combustion engines located away from combustibles.

(2) Smoking is prohibited in fire hazard areas (flammables, combustibles, etc.).

C. INDOOR STORAGE (OSHA 1926.151[d])

(1) Site kept free from accumulation of unnecessary combustibles.

(2) Storage shall not obstruct means of egress.

(3) Minimum clearance maintained around lights and heating units.

D. FLAMMABLE AND COMBUSTIBLE LIQUIDS (OSHA 1926.152)

(1) Stored in approved containers only.

(2) No storage in areas of exits, stairways or pedestrian traffic.

(3) Maximum in room storage of 25 gal., otherwise store in approved cabinet.

E. TEMPORARY HEATING DEVICES (OSHA 1926.154)

(1) Adequate ventilation for workmen and heater combustion.

(2) Minimum clearance (at least 3 feet) of combustibles from heaters.

(3) Stability of heater.

F. SIGNS AND BARRICADES (OSHA 1926.200)

(1) Danger signs where immediate hazards exist.

(2) Caution signs where potential hazards exist.

(3) Safety instruction signs, where necessary.

(4) Barricades to protect persons from hazards, where necessary.

G. WELDING AND CUTTING (NFPA-51B & OSHA 1910.252) - HOT WORK PERMIT

(1) Inspection of area before permit given.

(2) Minimum distance of 35 feet from combustibles.

(3) Properly rated fire extinguisher in immediate area.

General Requirements – Attachment #4 Page 1

(4) Wall and floor openings covered.

(5) No flammable liquids present.

(6) Inspection after work.

H. ELECTRICAL (OSHA 1924.400-2, 1926.302, & NFPA 241-4)

(1) All temporary wiring grounded and in accordance with National Electric Code (NEC).

(2) Precautions taken to make any open wiring inaccessible to other than authorized personnel.

(3) Temporary light bulbs equipped with guards, heavy duty cords, and not suspended by their cords (unless specifically designed for that use.)

(4) Runs of open conductors located away from possible damage and fastened at intervals of no greater than 10 feet.

(5) Outlets in construction sites have GFCI or assured equipment grounding.

(6) Extension cords protected from damage. No worn or frayed cables. Not hung from nails or suspended by wire.

(7) Fuses or circuit breaker provided for each feeder or branch circuit.

(8) Electrical powered operated hand tools shall either be of the approved double insulated type or properly grounded.

I. DEMOLITION (OSHA 1926.850-858 and NFPA 241 – Ch.7)

(1) Electric, gas, water, steam, etc. shut off prior to work.

(2) Any utilities that are necessary to be maintained need protection.

(3) Masonry walls shall not be permitted to fall on floors such that it would exceed the safe carrying capacity of the floor.

(4) Floor openings within 10 feet of any wall being demolished shall be planked solid except when no one below.

(5) The storage of waste material and debris shall not exceed the floor loading limit.

(6) Construction of dust barriers as needed (not OSHA).

(7) Notification of shut off and protect smoke detectors, etc. during day time only (not OSHA).

Coordinated with COTR.

(8) Precautions if floors are soaked with oil or flammable liquids, if dust accumulation is present or other combustibles a present and hot work is being performed.

(9) Smoking is prohibited throughout demolition (NFPA 241, 7-4, 2).

(10) Flammable and combustible liquids removed from area.

(11) Water supplies must be available from fire hydrants in the vicinity of the structure or area.

(12) Prior to demolition, asbestos abatement and breakables (i.e., glass) shall be removed.

General Requirements – Attachment #4 Page 2

J. TEMPORARY BUILDINGS, TRAILERS (NFPA 241, Ch.2)

(1) Temporary offices, trailers, sheds, etc. of combustible construction at least 30 feet from permanent buildings.

(2) Safety Office approved only heating devices installed. Per NFPA 211, maintain minimum clearance around stoves, heaters and chimneys.

K. ROOFING OPERATIONS (NFPA 241, Ch.6)

(1) Asphalt and tar kettles located outside the building or on a noncombustible roof away from combustibles. Kettles must have gravity lids, tight fitting.

(2) Torch applied roofing systems shall be installed using extreme caution. Follow manufacturer’s instructions. Caution around roof openings, penetrations or flashings.

(3) Fire extinguisher, 20-B minimum, within 30 feet of roof kettle. At least one extinguisher

2A:20-B:C on the roof being repaired; also one within 30 feet of torch applied roofing equipment.

(4) Fuel containers at least 10 feet away from burner flame.

(5) Notify building occupants who might be affected. Coordinate with COTR.

(6) Investigate location of supply air intakes. Coordinate shutdowns as necessary with COTR.

(7) Roof edges shall be guarded by typical roof protection or a safety monitoring system.

L. EXIT PATHWAYS (NFPA 241, Ch.5; also reference NFPA 101)

(1) Every building and area will remain accessible to fire department apparatus and personnel.

Roadways will be maintained with 20 feet of all buildings.

(2) Adequate egress paths, including stairs and corridors, will be maintained at all times. Exits may only be blocked temporarily if unavoidable and when adequate alternate measures are provided (signage, temporary fire detection, training, etc.) to warn personnel. Coordinate with

COTR.

WORK LOCATION:

NAME & PHONE No.:

General Requirements – Attachment #4 Page 3

CONSTRUCTION FIRE SAFETY CHECK LIST

Project # and Title:

Date:

Check Box3: Off

Check Box4: Off

Check Box5: Off

Check Box6: Off

Check Box7: Off

Check Box8: Off

Check Box9: Off

Check Box10: Off

Check Box11: Off

Check Box12: Off

Check Box13: Off

Check Box14: Off

Check Box15: Off

Check Box16: Off

Check Box17: Off

Check Box18: Off

Check Box19: Off

Check Box21: Off

Check Box22: Off

Check Box23: Off

Check Box24: Off

Check Box25: Off

Check Box26: Off

Check Box27: Off

Check Box28: Off

Check Box29: Off

Check Box30: Off

Check Box31: Off

Check Box32: Off

Check Box33: Off

Check Box34: Off

Check Box35: Off

Check Box36: Off

Check Box37: Off

Check Box38: Off

Check Box39: Off

Check Box40: Off

Check Box41: Off

Check Box42: Off

Check Box43: Off

Check Box44: Off

Check Box45: Off

Check Box46: Off

Check Box47: Off

Check Box48: Off

Check Box49: Off

Check Box50: Off

Check Box51: Off

Check Box52: Off

Check Box53: Off

Check Box54: Off

Check Box55: Off

Check Box56: Off

Check Box57: Off

Work Location:

Name and Phone #:

Contractor:

Clear:

Print:

Contract Information:

Attachments 5a & 5b

Contractor Work Plan & Peer Review

ATTACHMENT #5 - A

CONTRACTOR WORK PLAN / PEER REVIEW REQUEST

DESCRIPTION OF WORK:

TOOLS & EQUIPMENT TO PERFORM WORK:

PERSONAL PROTECTIVE EQUIPMENT FOR WORK:

NAME(S) OF EMPLOYEE(S) PERFORMING WORK:

SUPERVISOR / WORK LEADER NAME (PRINTED):

SUPERVISOR / WORK LEADER SIGNATURE:

Section 01 00 00, General Requirements – Attachment #5 - A

Revised Mar 2019

Su M T W Th F Sa DATE: @ TIME: START DATE:

END DATE: DATE: @ TIME:

ESTIMATED DURATION OF WORK:

LOCATION OF WORK:

HOURS

ARC CAL: PPE LEVEL 1 2 3 4

Su M T W Th F Sa

PROCEDURE(S):

All maintenance and repair work must have a written procedure prepared by the maintenance person performing the task.

BEFORE:

DURING:

AFTER:

DATE AND TIME COR NOTIFIED:

GENERAL CONTRACTOR’S NOTIFYING PERSON:

NOTIFYING PERSON’S SIGNATURE:

GENERAL CONTRACTOR COMPANY:

PHONE NUMBER(S) –

OFFICE:

CELL:

PEER REVIEW #5 – B

* - Designates signature required.

General Requirements – Attachment #5 – B

Name Signature Title / Service Date

*COR / FMS

*Elec Supv / FMS

*AC Supv / FMS

*Plumb Supv / FMS

*CEP / FMS

*M&O Supv / FMS

*Projects Supv / FMS

*Safety / FMS

*BioMed / FMS

*Chief / FMS

*Infect Ctrl / MED

*Logistics

*SPD/SPS

*Police

*AFGE

*NNU

Power Plant / FMS

*OI&T

General Requirements – Attachment #5 – B

AREA IMPACTED REPRESENTRATIVE SIGN OFF / MEETING SIGN IN SHEET

MEETING DAY/DATE/TIME:

PLEASE PRINT AND SIGN YOUR NAME

AND PROVIDE BEST CONTACT INFO:

Print Name: Signature:

Dept/Company: Phone/Ext:

Check all that apply:

Notification of Live Electrical Work Mitigation Plan

Enclosed Space Permit Contingency Plan

Burn Permit (Hot Work) Utility Shutdown required?

Safety Review (ILSM) Coordination Meeting Required?

Infection Controls Review (ICRA) Utility Shutdown / Closure Notice

Above Ceiling Permit Utility Shutdown & Start Up Procedures

Drawings Enclosed Shutdown Checklist and Flow Chart

RESET PRINT

General Requirements – Attachment #5 - B

2019-Feb-07 VA 01 00 00 General Requirements - Attachment 5a and 5b.pdf

Attachment5-Page2.pdf

PROJECT No TITLE:

TIME:

TIME_2:

LOCATION OF WORK:

DESCRIPTION OF WORK:

TOOLS EQUIPMENT TO PERFORM WORK:

PERSONNAL PROTECTIVE EQUIPMENT FOR WORK:

NAMES OF EMPLOYEES PERFORMING WORK:

SUPERVISOR WORK LEADER NAME PRINTED:

Supervisr/Work Leader Signed:

Date_Supervisor/work leader signed:

Group17: Off

Group18: Off

Duration:

Start Date:

End Date:

Group1: Off

ArcCal:

PROCEDURES:

BEFORE:

DURING:

AFTER:

DATE AND TIME COR NOTIFIED:

GENERAL CONTRACTORS NOTIFYING PERSON:

GENERAL CONTRACTOR COMPANY:

OFFICE:

CELL:

PROJECT No TITLE_2:

NameRow1:

SignatureRow1:

DateCOR FMS:

NameRow2:

SignatureRow2:

DateElec Supv FMS:

NameRow3:

SignatureRow3:

DateAC Supv FMS:

NameRow4:

SignatureRow4:

DatePlumb Supv FMS:

NameRow5:

SignatureRow5:

DateCEP FMS:

NameRow6:

SignatureRow6:

DateMO Supv FMS:

NameRow7:

SignatureRow7:

DateProjects Supv FMS:

NameRow8:

SignatureRow8:

DateSafety FMS:

NameRow9:

SignatureRow9:

DateBioMed FMS:

NameRow10:

SignatureRow10:

DateChief FMS:

NameRow11:

SignatureRow11:

DateInfect Ctrl MED:

NameRow12:

SignatureRow12:

DateLogistics:

NameRow13:

SignatureRow13:

DateSPDSPS:

NameRow14:

SignatureRow14:

DatePOLICE:

NameRow15:

SignatureRow15:

Dat…