S02 - 1 Hines Documents for Construction.pdf

Table of Contents

These documents are all included in the Hines Documents for Construction file.

1) Hines Underground Utility Plan

2) HINES VA SITE PLAN 5-1-2025

3) Parking Designations 08042025

4) Contractor Badging - Fingerprint Request Form 2025

5) Safety and Health During Construction Activities

6) Pre-Construction Checklist Rev 07.27.2021

7) Infection Control Barrier Sample

8) Dig Permit SOP Form

9) Above Ceiling Permits

10) Fire Protection Code Reviews

11) No Smoking Policy 10-1-19

12) Cutting Welding and Other Hot Work

13) Asbestos Survey Glossary

14) OIT Horizontal Cable Requirements

15) Hines COVID-19 Guidelines

16) Emergency Contact List – Template

17) VHA Supplemental Contract Requirements for Ensuring Adequate COVID-19 Safety Protocols for

Federal Contractors rev2

UTILITY LEGEND

UE

BURIED ELECTRIC

BT

BURIED TELEPHONE

FOC

BURIED FIBER OPTIC CABLE

CTV

BURIED CABLE TV

GAS

GAS

W

WATER

STM

STEAM

UNK

BURIED UNKNOWN UTILITY

FL

FUEL LINE

O

OXYGEN LINE

SS

SANITARY SEWER

ST

STORM SEWER

CIVIL ENGINEERING * TRANSPORTATION * ENVIRONMENTAL

* PLANNING * UTILITY ENGINEERING/LOCATING

ELECTRIC PEDESTAL

METER

STORM INLET

STORM MANHOLE

MANHOLE

MANHOLE

MANHOLE

VAULT

SANITARY MANHOLE

METER

VAULT

HANDHOLE

Contractor Parking

Lot

Gravel Parking Lot 1

P a rk in g L o t

I

Parking Lot D

Valet Parking

Lot

Virginia Parking

Lot

Wisconsin Parking

Lot

Parking Lot A

Parking Lot B

Parking Lot C

Gravel Parking

Lot 2

Illinois Parking

Lot

Nebraska Parking

Lot

Io w a P a rk in g

L o t Missouri Parking

Lot

Arkansas Parking Lot

Parking Lot E

Parking Lot K

Parking Lot L

Oklahoma Parking Lot

P a rk in g

L o t

T

A la b a m a

P a rk in g L o t

Parking Lot G

Parking Lot M

Parking Lot N

Parking Lot H

Parking Lot J

Parking Lot P

Leased Parking

Lot

Parking Lot Q

Parking Lot R

Parking Lot S

NORTH SOUTH

EAST

WEST

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17TH STREET

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AutoCAD SHX Text 5-1-2025

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AIR MAIL ROAD

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5TH AVENUE

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5TH AVENUE

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5TH AVENUE

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TRIPP AVENUE

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TRIPP AVENUE

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THE

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FIRST AVENUE

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SCOTT DRIVE

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CROSSMAN CIRCLE

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CROSSMAN CIRCLE

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FEARS DRIVE

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WEST "B"STREET

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ROOSEVELT RD.

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HINES BOULEVARD

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HOUSE

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RONALD

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AIR MAIL ROAD

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STORAGE

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MASONRY

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BLDG. 1

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NINTH AVENUE

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SCOTT DRIVE

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13TH ST.

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TRIPP AVENUE

AutoCAD SHX Text McCOY DRIVE

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CIRCLE

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CROSSMAN

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HINES BOULEVARD

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17TH ST.

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16TH ST.

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15TH ST.

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14TH ST.

AutoCAD SHX Text X

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SCALE: 1" = 130-0"

AutoCAD SHX Text Veterans Affairs

AutoCAD SHX Text Department of

AutoCAD SHX Text Date

AutoCAD SHX Text Project No.

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DRAWING NO.

AutoCAD SHX Text Drawn

AutoCAD SHX Text Dwg. Of

AutoCAD SHX Text Office of Facilities

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AutoCAD SHX Text Location

AutoCAD SHX Text Building No.

AutoCAD SHX Text Project Title

AutoCAD SHX Text Approved: Service Director

AutoCAD SHX Text Approved: Division Chief

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V.A. HOSPITAL, HINES, IL

AutoCAD SHX Text Checked

AutoCAD SHX Text Hines VA Campus Map

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BUILDING DIRECTORY

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PUMP HOUSE

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AT&T

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UNDERGROUND STORAGE TANK

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UNDERGROUND STORAGE TANK

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FREEDOM'S PATH HOUSING 240

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AutoCAD SHX Text Basketball Court

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FREEDOM'S PATH 2 HOUSING 242

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AutoCAD SHX Text 1 OUTPATIENT CLINICS, ADMINISTRATION OUTPATIENT CLINICS, ADMINISTRATION OFFICES AND RESEARCH OFFICES AND RESEARCH 2 ENGINEERING, FISCAL, AND SAFETY ENGINEERING, FISCAL, AND SAFETY OFFICES 3 PIPE SHOP PIPE SHOP 4 OEF/OIF OEF/OIF 5 BOILER PLANT (OLD) BOILER PLANT (OLD) 7 STRUCTURES SHOP STRUCTURES SHOP 8 ENGINEERING, MRW, POLICE ENGINEERING, MRW, POLICE 9 AUDITORIUM, RECREATION AND AUDITORIUM, RECREATION AND VOLUNTARY SERVICES 12 EMPLOYEE GYM, COMPENSATION AND EMPLOYEE GYM, COMPENSATION AND PENSION 13 COUNSELING CENTER COUNSELING CENTER 14 COOKE'S MANOR COOKE'S MANOR FREEDOMS PATH 3 (EUL) 15 UNDERGROUND WATER RESERVOIR UNDERGROUND WATER RESERVOIR (700,000 GALLONS) 16 INSPECTOR GENERAL'S OFFICE OF INSPECTOR GENERAL'S OFFICE OF AUDIT

AutoCAD SHX Text 17 HUMAN RESOURCES HUMAN RESOURCES 18 VIREC VIREC 20 MOTOR POOL MOTOR POOL 21 MAINTENANCE STORAGE MAINTENANCE STORAGE 30 EMS STORAGE EMS STORAGE 33 RADIATION LABORATORY RADIATION LABORATORY 34 GEORGE DILBOY MEMORIAL STATUE GEORGE DILBOY MEMORIAL STATUE 35 MAIN GATE HOUSE MAIN GATE HOUSE 37 NAC/CMOP NAC/CMOP 42 FLAG POLE FLAG POLE 45 CANTEEN CANTEEN 46 FORMER GOLF COURSE FORMER GOLF COURSE RECREATIONAL BUILDING 47 GAS METER HOUSE GAS METER HOUSE 48 LAUNDRY DISTRIBUTION LAUNDRY DISTRIBUTION 53 CATHOLIC CHARITIES (EUL) CATHOLIC CHARITIES (EUL) 100 FISHER HOUSEFISHER HOUSE

AutoCAD SHX Text 221 RESIDENTIAL CARE FACILITY (RCF) LONG-TERM SPINAL CORD INJURY UNIT 221A LIBERTY TRAILER LIBERTY TRAILER 222 EMERGENCY GENERATOR EMERGENCY GENERATOR 223 EMERGENCY GENERATOR EMERGENCY GENERATOR 224 EMERGENCY GENERATOR EMERGENCY GENERATOR 225 EMERGENCY GENERATOR EMERGENCY GENERATOR 226 EMERGENCY GENERATOR EMERGENCY GENERATOR 227 EMERGENCY GENERATOR EMERGENCY GENERATOR 228 MENTAL HEALTH BUILDING MENTAL HEALTH BUILDING 229 RESEARCH RESEARCH 230 EMS EMS 231 SALT STORAGE SALT STORAGE 232 RONALD McDONALD HOUSE (EUL) RONALD McDONALD HOUSE (EUL) 235 HAZARDOUS WASTE SHED HAZARDOUS WASTE SHED 240 FREEDOMS PATH 1 (EUL) FREEDOMS PATH 1 (EUL) 242 FREEDOMS PATH 2 (EUL)

AutoCAD SHX Text 113 BLIND REHABILITATION CENTER (BRC) BLIND REHABILITATION CENTER (BRC) 128 SPINAL CORD INJURY AND DISORDERS SPINAL CORD INJURY AND DISORDERS CENTER (SCI) 195 WATER TOWER (1,000,000 GALLONS) WATER TOWER (1,000,000 GALLONS) 197 VALVE HOUSE VALVE HOUSE 200 MAIN HOSPITAL MAIN HOSPITAL 201 OXYGEN STORAGE OXYGEN STORAGE 202 ELECTRICAL SUBSTATION ELECTRICAL SUBSTATION 203 PATIENT RECREATION PAVILION PATIENT RECREATION PAVILION 205 BOILER PLANT (NEW) BOILER PLANT (NEW) 206 WATER RESERVOIR - ABOVE GROUND WATER RESERVOIR - ABOVE GROUND 215 DATA PROCESSING CENTER DATA PROCESSING CENTER 217 COMMUNITY LIVING CENTER (CLC) COMMUNITY LIVING CENTER (CLC) 218 EMERGENCY GENERATOR FOR BLDG. 217 EMERGENCY GENERATOR FOR BLDG. 217 219 CHILLER FOR BLDG. 217 CHILLER FOR BLDG. 217 220 WAREHOUSE/SERVICE BUILDING, POST WAREHOUSE/SERVICE BUILDING, POST OFFICE, BARBER SHOP

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E85 STATION

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GARAGE

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5TH AVENUE

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DETENTION POND

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DETENTION POND

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FEARS DRIVE

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HINES SITE PLAN

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VHAHINKanurJ Polygon

VHAHINKanurJ Architect Missouri Parking Lot

VHAHINKanurJ Architect

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VHAHINKanurJ Architect

VHAHINKanurJ Engineer Parking Lot I

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VHAHINKanurJ Rectangle

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VHAHINKanurJ Text Box 4-03-2025

VHAHINKanurJ Text Box

2025 ENGINEERING SERVICE

PROJECT PLANNING CONTRACTOR

FINGERPRINT REQUEST FORM

Bring with you two (2) original IDs (Identity Source Documents).

Complete all yellow highlighted fields on this form to the best of your ability

Applicant Category: Check One (APPLICATION RENEWABLE IN 182 DAYS)

EMPLOYEE ✔ CONTRACTOR

HEALTH PROFESSONS TRAINEE,

resident (VHA intern, fellow, student)

AFFILIATE

VOLUNTEER

OTHER/CONTRACTED

EMPLOYEE

ENTER YOUR NAME EXACTLY AS IT APPEARS ON IDs

Name: (Last, First, Middle)

Other Last Names Used

SSN (use of pseudo number is not permitted)

Position Title

Telephone #

Date of Birth: (mm/dd/yyyy)

City/State and Country of Birth

E-Mail Address

Country of Citizenship

Dual Citizen?

VA Work Location

Name of Sponsor: Sponsor Phone:

Contractors Only: Company Name

Company Address/Work Email

Contract Start Date

Name of Project COR

Project #

Project End Date

FINGERPRINT LOCATION

Edward Hines Jr VAMC

FINGERPRINT DATE (mm/dd/yyyy)

PREVIOUS VA PIV CARD HOLDER (Yes/No)

GENDER (M/F)

HEIGHT (inches)

WEIGHT (US pounds)

HAIR COLOR

EYE COLOR

RACE/ETHNICITY

Facility Name Location:

Hines – 578 VISN 12

Facility SOI # Facility SON #

Date Cleared Signature

Comments

Mikel Jones, mikel.jones@va.gov 708 202-8387 ext 21322

PSAC-VACO 430H

Identifying documents NOT

ACCEPTED by USAccess include, but are not limited to:

1. Student ID Cards (including public/state universities, as well as private universities)

2. Gun or Firearms permits

3. License to Carry

4. Hunting/Fishing permits

5. Facility Badge

6. Temporary driver’s licenses

7. Selective service card

8. Company ID Card

9. Foreign Driver’s License (other than Canada)

10. Library Card

11. Temporary PIV Card

12. Marriage license

Primary Forms of Identification (Acceptable

Documents)

1. U.S. Passport or a U.S. Passport Card

2. Permanent Resident Card or an Alien Registration Receipt Card (Form I-

551)

3. Foreign passport

4. Employment Authorization Document that contains a photograph (Form I-

766)

5. Driver's license or an ID card issued by a state or possession of the United

States provided it contains a photograph

6. U.S. Military ID card

7. U.S. Military dependent's ID card; or

8. PIV Card.

Issue No. 20-

USAccess Deployment Bulletin

USAccess Identity Proofing Source Documents

Week of December 28, 2020

Email CM PMO

Weekly Bulletin Archive

Click here to Unsubscribe

Identifying Source

Documents Not Accepted for USAccess is Coming… Are You Ready?

Issue No. 20-45

USAccess Enrollment and Identity Proofing Documents

Secondary Forms of Identification (Acceptable

Documents)

1. U.S. Social Security Card issued by the Social Security Administration.

Laminated SSA cards cannot be used without Security Officer approval.

2. Original or certified copy of a birth certificate issued by a state, county, municipal authority, possession, or outlying possession of the United

States bearing an official seal

3. ID card issued by a federal, state, or local government agency or entity, provided it contains a photograph. EXCEPTIONS APPLY

4. Voter's registration card; 13. Reentry Permit (Form I-327)

5. U.S. Coast Guard Merchant Mariner Card

6. Certificate of U.S. Citizenship (Form N-560 or N-561)

7. Certificate of Naturalization (Form N-550 or N-570)

8. U.S. Citizen ID Card (Form I-197)

9. Identification Card for Use of Resident Citizen in the United States (Form I-

179)

10. Certification of Birth Abroad or Certification of Report of Birth issued by the

Department of State (Form FS545 or Form DS-1350)

11. Temporary Resident Card (Form I-688)

12. Employment Authorization Card (Form I-688A)

13. Reentry Permit (Form I-327)

14. Refugee Travel Document (Form I-571)

15. Employment authorization document issued by Department of Homeland

Security (DHS)

16. Employment Authorization Document issued by DHS with photograph

(Form I-688B)

17. Driver's license issued by a Canadian government entity

18. Native American tribal document.

The following rules apply to all presented identity source documents:

• All documents must be in their original forms - no photocopies other than a certified copy of birth certificate bearing an official seal.

• Expired or canceled identity documents are not a cceptable.

• All Primary forms of ID contain an expiration date;

however, some Secondary forms of ID do not. Not having an expiration date does not make a

Secondary ID Source unacceptable. Secondary forms of ID without an expiration date can be accepted.

• Up dating or replacing identity source documents is n o t required after successfully completing the id entity proofing process.

• If any of the identity source documents presented for identity proofing bear different names, then evidence of a formal name change must be provided linking the names. For example, a married woman with a current driver’s license and birth certificate can provide a marriage license.

Photos are required for all forms of primary identification documents.

mailto:vacohspd12pmo@va.gov http://vaww.oicam.va.gov/pscm/credential-management/communications/ mailto:vacohspd12pmo@va.gov?subject=Unsubscribe VHAHINDoyleL Text Box Real ID required

VHAHINDoyleL Text Box Real ID required

Form Approved:

OMB No. 3206-0182 Declaration for Federal Employment*

(*This form may also be used to assess fitness for federal contract employment)

Instructions The information collected on this form is used to determine your acceptability for Federal and Federal contract employment and your enrollment status in the Government's Life Insurance program. Most applicants are asked to complete this form after a tentative offer of employment has been made; however, depending on your position, you may be asked to complete this form earlier during the hiring process. Follow instructions that the agency provides. Before you are appointed you will be asked to update your responses on this form and on other materials submitted during the application process and then to recertify that your answers are true.

All your answers must be truthful and complete. A false statement on any part of this declaration or attached forms or sheets may be grounds for not hiring you, or for firing you after you begin work. Also, you may be punished by a fine or imprisonment (U.S. Code, title 18, section 1001).

Either type your responses on this form or print clearly in dark ink. If you need additional space, attach letter-size sheets (8.5" X 11").

Include your name, Social Security Number, and item number on each sheet. We recommend that you keep a photocopy of your completed form for your records.

Privacy Act Statement The Office of Personnel Management is authorized to request this information under sections 1302, 3301, 3304, 3328, and 8716 of title 5, U. S. Code. Section 1104 of title 5 allows the Office of Personnel Management to delegate personnel management functions to other Federal agencies. If necessary, and usually in conjunction with another form or forms, this form may be used in conducting an investigation to determine your suitability or your ability to hold a security clearance, and it may be disclosed to authorized officials making similar, subsequent determinations.

Your Social Security Number (SSN) is needed to keep our records accurate, because other people may have the same name and birth date. Public Law 104-134 (April 26, 1996) asks Federal agencies to use this number to help identify individuals in agency records. Giving us your SSN or any other information is voluntary. However, if you do not give us your SSN or any other information requested, we cannot process your application. Incomplete addresses and ZIP Codes may also slow processing.

ROUTINE USES: Any disclosure of this record or information in this record is in accordance with routine uses found in System Notice OPM/GOVT-1, General Personnel Records. This system allows disclosure of information to: training facilities; organizations deciding claims for retirement, insurance, unemployment, or health benefits; officials in litigation or administrative proceedings where the Government is a party; law enforcement agencies concerning a violation of law or regulation; Federal agencies for statistical reports and studies; officials of labor organizations recognized by law in connection with representation of employees; Federal agencies or other sources requesting information for Federal agencies in connection with hiring or retaining, security clearance, security or suitability investigations, classifying jobs, contracting, or issuing licenses, grants, or other benefits; public and private organizations, including news media, which grant or publicize employee recognitions and awards; the Merit Systems Protection Board, the Office of Special Counsel, the Equal Employment Opportunity Commission, the Federal Labor Relations Authority, the National Archives and Records Administration, and Congressional offices in connection with their official functions; prospective non-Federal employers concerning tenure of employment, civil service status, length of service, and the date and nature of action for separation as shown on the SF 50 (or authorized exception) of a specifically identified individual; requesting organizations or individuals concerning the home address and other relevant information on those who might have contracted an illness or been exposed to a health hazard; authorized Federal and non-Federal agencies for use in computer matching; spouses or dependent children asking whether the employee has changed from a self-and-family to a self-only health benefits enrollment; individuals working on a contract, service, grant, cooperative agreement, or job for the Federal government; non-agency members of an agency's performance or other panel; and agency-appointed representatives of employees concerning information issued to the employees about fitness-for-duty or agency-filed disability retirement procedures.

Public Burden Statement Public burden reporting for this collection of information is estimated to vary from 5 to 30 minutes with an average of 15 minutes per response, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding the burden estimate or any other aspect of the collection of information, including suggestions for reducing this burden, to the U.S. Office of Personnel Management, Reports and Forms Manager (3206-0182), Washington, DC 20415-7900. The OMB number, 3206-0182, is valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

General Information

1. FULL NAME (Provide your full name. If you have only initials in your name, provide them and indicate "Initial only". If you do not have a middle name, indicate "No Middle Name". If you are a "Jr.," "Sr.," etc. enter this under Suffix. First, Middle, Last, Suffix)

2. SOCIAL SECURITY NUMBER 3a. PLACE OF BIRTH (Include city and state or country)

3b. ARE YOU A U.S. CITIZEN?

YES NO (If "NO", provide country of citizenship)

4. DATE OF BIRTH (MM / DD / YYYY)

5. OTHER NAMES EVER USED (For example, maiden name, nickname, etc.) 6. PHONE NUMBERS (Include area codes)

Day

Night

Selective Service Registration If you are a male born after December 31, 1959, and are at least 18 years of age, civil service employment law (5 U.S.C. 3328) requires that you must register with the Selective Service System, unless you meet certain exemptions.

7a. Were you born a male after December 31, 1959? YES NO (If "NO", proceed to 8.)

7b. Have you registered with the Selective Service System? YES (If "YES", proceed to 8.) NO (If "NO", proceed to 7c.)

7c. If "NO," describe your reason(s) in item 16.

(*This form may also be used to assess fitness for federal contract employment)

Military Service

8. Have you ever served in the United States military? YES (If "YES", provide information below) NO

If your only active duty was training in the Reserves or National Guard, answer "NO.”

If you answered "YES," list the branch, dates, and type of discharge for all active duty.

Branch From (MM/DD/YYYY) To (MM/DD/YYYY) Type of Discharge

Background Information For all questions, provide all additional requested information under item 16 or on attached sheets. The circumstances of each event you list will be considered. However, in most cases you can still be considered for Federal jobs.

For questions 9,10, and 11, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state law .

9. During the last 7 years, have you been convicted, been imprisoned, been on probation, or been on parole?

(Includes felonies, firearms or explosives violations, misdemeanors, and all other offenses.) If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the police department or court involved.

YES NO

10. Have you been convicted by a military court-martial in the past 7 years? (If no military service, answer "NO.") If "YES," use item 16 to provide the date, explanation of the violation, place of occurrence, and the name and address of the military authority or court involved.

YES NO

11. Are you currently under charges for any violation of law? If "YES," use item 16 to provide the date, explanation of the charges, place of occurrence, and the name and address of the police department or court involved.

YES NO

12. During the last 5 years, have you been fired from any job for any reason, did you quit after being told that you would be fired, did you leave any job by mutual agreement because of specific problems, or were you debarred from Federal employment by the Office of Personnel Management or any other Federal agency? If "YES," use item 16 to provide the date, an explanation of the problem, reason for leaving, and the employer's name and address.

YES NO

13. Are you delinquent on any Federal debt? (Includes delinquencies arising from Federal taxes, loans, overpayment of benefits, and other debts to the U.S. Government, plus defaults of Federally guaranteed or insured loans such as student and home mortgage loans.) If "YES," use item 16 to provide the type, length, and amount of the delinquency or default, and steps that you are taking to correct the error or repay the debt.

YES NO

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

(*This form may also be used to assess fitness for federal contract employment)

Additional Questions

14. Do any of your relatives work for the agency or government organization to which you are submitting this form?

(Include: father, mother, husband, wife, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother, and half-sister.) If "YES," use item 16 to provide the relative's name, relationship, and the department, agency, or branch of the Armed Forces for which your relativeworks.

YES NO

15. Do you receive, or have you ever applied for, retirement pay, pension, or other retired pay based on military, Federal civilian, or District of Columbia Government service?

YES NO

Continuation Space / Agency Optional Questions

16. Provide details requested in items 7 through 15 and 18c in the space below or on attached sheets. Be sure to identify attached sheets with your name, Social Security Number, and item number, and to include ZIP Codes in all addresses. If any questions are printed below, please answer as instructed (these questions are specific to your position and your agency is authorized to ask them).

Certifications / Additional Questions APPLICANT: If you are applying for a position and received a tentative/conditional job offer or have not yet been selected, carefully review your answers on this form and any attached sheets.

APPOINTEE: If you are being appointed, carefully review your answers on this form and any attached sheets, including any other application materials that your agency has attached to this form. If any information requires correction to be accurate as of the date you are signing, make changes on this form or the attachments and/or provide updated information on additional sheets, initialing and dating all changes and additions.

When this form and all attached materials are accurate, read item 17, complete 17b, read 18, and answer 18a, 18b, and 18c as appropriate.

17. I certify that, to the best of my knowledge and belief, all of the information on and attached to this Declaration for Federal Employment, including any attached application materials, is true, correct, complete, and made in good faith. I understand that a false or fraudulent answer to any question or item on any part of this declaration or its attachments may be grounds for not hiring me, or for firing me after I begin work, and may be punishable by fine or imprisonment. I understand that any information I give may be investigated for purposes of determining eligibility for Federal employment as allowed by law or Presidential order. I consent to the release of information about my ability and fitness for Federal employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, personnel specialists, and other authorized employees or representatives of the Federal Government. I understand that for financial or lending institutions, medical institutions, hospitals, health care professionals, and some other sources of information, a separate specific release may be needed, and I may be contacted for such a release at a later date.

17a. Applicant's Signature: Date:

(MM / DD / YYYY)

17b. Appointee's Signature: Date:

(MM / DD / YYYY)

18. Appointee (Only respond if you have been employed by the Federal Government before): Your elections of life insurance during previous Federal employment may affect your eligibility for life insurance during your new appointment. These questions are asked to help your personnel office make a correct determination.

18a. When did you leave your last Federal job? Date:

(MM / DD / YYYY)

18b. When you worked for the Federal Government the last time, did you waive Basic Life Insurance or any type of optional life insurance?

YES NO DO NOT KNOW

18c. If you answered "YES" to item 18b, did you later cancel the waiver(s)? If your answer to item 18c is "NO," use item 16 to identify the type(s) of insurance for which waivers were not canceled.

YES NO DO NOT KNOW

U.S. Office of Personnel Management

5 U.S.C. 1302, 3301, 3304, 3328 & 8716

Optional Form 306 Revised August 2023

Previous editions obsolete and unusable

Appointing Officer:

Enter Date of Appointment or Conversion

MM / DD / YYYY

DEPARTMENT OF VETERANS AFFAIRS

PERSONNEL SECURITY ADJUDICATION CENTER

Self Certification of Continuous Service

I hereby certify my break in service from my last federal employment is indicated by the block checked below.

I have NOT had a break in service.

My break in service was less than 60 days.

My break in service was greater than 60 days, but less than two (2) years. (You are required to submit the OF 306, Declaration for Federal

Employment, with this form.)

My break in service is greater than two (2) years; or I have never had federal employment as defined above.

Print Name: Social Security Number:

Signature: Date:

VA Personnel Security/HR Use Only:

Current Investigation in PIPS: Date:

Risk level of current position: Verified by:

(Check One)

Federal employment is defined as any branch of the United States military (Active, Guard or Reserve), federal government civilian employee (any federal government agency), or a contractor working for the federal government.

Self Certification of Continuous Service Form Revised February 28, 2020

Previous Versions are Obsolete

VA Hospital Policy Memorandum 578-12-138A-076 (R-2) Hines, IL 60141 July 16, 2018

SAFETY AND HEALTH DURING CONSTRUCTION ACTIVITIES

Changes:

• 3 Responsibilities:

Revised Section a. (2) to remove Engineering (Facilities Management) and Engineering (Projects Management) and to include Engineer (Project Planning Section), Engineering (Maintenance and Operations), and Engineering (Healthcare Technology Management).

Revised Section a. (3) from "complete at least 10 hours of Construction Safety Training at least every 2 years; or complete 30 hours of Construction Safety Training" to "complete 30-hour Construction Safety Training and subsequently completes at least 10 hours of Construction Safety Training at least every 2 years."

Changed the title of Section c from Chief, Facilities Management Service to Chief, Engineering Service.

Changed the title of Section c from Chief, Biomedical Engineering to Chief, Healthcare Technology Management.

Correcting Section h. (3) to correctly indicate "CSO(s)" instead of "CSC(s)".

Changed the title of Section i from Facility Safety Program Manager or designee to Safety and Occupational Health Manager or designee.

Changed the title of Section h from Infection Prevention ist to Infection Control Manager or designee.

• 5 References:

Replaced reference VHA Directive 2011-036, Safety and Health During Construction Activities, dated September 22, 2011 (Data available on Intranet) with VHA Directive 7715, Safety and Health During Construction, dated April 6, 2017 (Data available on Intranet)

Replaced reference Interim Life Safety Measures, Policy Memorandum 578-02-001-088(R-2), dated October 3, 2011 (Data available on intranet) with Interim Life Safety Measures, Policy Memorandum 578-02-001-088 (R-3), or more current version (Data available on intranet)

Replaced reference Above Ceiling Entry and Wall Construction Permits 578-07-001-102 (R-2) dated December 27, 2011 (Data available on Intranet) with Above Ceiling Entry and Wall

Construction Permits 578-12-138A-079 (R-3), or more current version (Data available on intranet)

Replaced reference Smoking Policy 578-03-001-038 (R-2) dated February 1, 2012 (Data available on intranet) with Smoking Policy 578-03-001-038 (R-3), or more current version (Data available on intranet)

Replaced reference Hazard Communication Program 578-03-001-034 (R-1) dated January 13, 2012 (Data Available on intranet) with Hazard Communication Program 578-03-001-034 (R-2), or more current version (Data available on intranet)

• 6 Rescission:

Changed to Policy 578-12-138A-076 (R1) Safety and Health During Construction Activities

• 8 Follow-up Responsibility:

Changed from Facilities Management Service to Engineering Service.

• 9 Attachments:

Created Section 9 and move the attachments list into this section.

• Signature Change

Changed Director's signature from Joan M. Ricard, FACHE, Hospital Director to Steven E.

Braverman, M.D., Hospital Director.

Removed from Previous Policy:

• 3 Responsibilities:

The Construction Safety Committee (Multi-Disciplinary Team), Section m. (2): Conducting preconstruction risk assessments for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.

Using the current American Institute of Architects (AIA) Guidelines, staff must conduct and document in writing preconstruction risk assessments during the design or planning stage of the work (prior to bidding, award, and starting work). Preconstruction risk assessments must focus on eliminating or minimizing the above-mentioned risks during construction and renovation activities. The complexity of the preconstruction risk assessment report is determined by the complexity of the threats posed by the construction project. Assigned VHA staff and Construction Facility Management Resident Engineers (CFM REs) must confirm compliance during the construction phase of the work.

The Construction Safety Committee (Multi-Disciplinary Team), Section m. (5): Participating in all phases of construction work from planning through completion. This includes review and approval of construction plans, contract specifications, and contract submittals related to construction safety and health and any other documents that may assist in the implementation of an effective Construction Safety Program. The Multi-Disciplinary Team must be involved early in the process and continue oversight on a regular basis to avoid costly and disruptive delays.

Education/Training: Engineering Service has already reviewed policy to include in-service training.

Related Forms: see attachments

Key words: safety, health, construction, activities

VA Hospital Policy Memorandum 578-12-138A-076 (R-2) Hines, IL 60141 July 16, 2018

SAFETY AND HEALTH DURING CONSTRUCTION ACTIVITIES

1. PURPOSE: To establish policy and procedures to ensure that construction projects will be planned, coordinated and regularly inspected to ensure compliance with applicable fire, infection control, environmental, security, safety, and occupational health regulations and policies.

2. POLICY:

a. To protect patients, staff, visitors, and contractors from safety and health hazards associated with construction activities, this policy is established for the Edward Hines Jr. VA Hospital (Hines VA) and for all property where construction is undertaken. This policy requires that strategies be established to control the hazards inherent in conducting construction or maintenance operations in areas that are occupied by patients, visitors, or healthcare staff. These strategies include the assignment of appropriate responsibility at all levels of the organization, establishing and maintaining the necessary expertise to manage an effective construction health and safety program, applying technical guidance and best practices to assist in managing the program, and providing a Construction Safety Committee to oversee and enforce the application of this policy.

b. Construction activities shall be defined to include delegated minor or non-recurring maintenance projects performed by contractors, station-level projects performed by contractors, and station Maintenance and Operations (M&O) personnel. Construction shall also include non-delegated projects including majors. Hines VA shall coordinate those construction impacts with the project's Project Engineer/Contracting Officers Representative (COR) through Hines VA single point of contact. This definition also applies to Enhanced Use and Lease (EUL) projects related to structures for which Hines VA maintains management responsibility or authority.

c. The intention of this Construction Safety Program is to reduce the potential for injury and illness to VA patients, employees, and visitors that might result from unsafe construction activities; to increase the level of construction safety expertise of VA employees; to decrease the potential for serious Occupational Safety and Health Administration (OSHA) violations; to provide a guideline for addressing safety-related construction issues; and to reduce the potential for property and liability exposures due to construction-related activities.

d. Proper application of this program will reduce the potential for liability, which could result from construction accidents, life safety deficiencies, or infection control failures.

3. RESPONSIBILITY:

a. VA Hospital Director:

(1) Establishing and monitoring an effective facility Construction Safety Program.

(2) Establishing a Multi-Disciplinary Team (Construction Safety Committee) with representatives from the following program areas:

• Infection Control

• Patient Safety

• Occupational Safety and Health

• Police

• Engineering (Project Planning Section)

• Engineering (Maintenance and Operations)

• Engineering (Healthcare Technology Management)

• Green Environmental Management System (GEMS)

• Emergency Planning Coordinator

• Local Union Safety Representatives (from affected bargaining units)

• Contracting

• Employee Occupational Health

(3) Ensuring that appropriate staff receives training in construction safety. All members of the Multi-Disciplinary Team complete 30-hour Construction Safety Training and subsequently completes at least 10 hours of Construction Safety Training at least every 2 years.

(4) Ensuring that the Construction Safety Committee actively engages in:

(a) Protecting patients, visitors, and employees from traumatic injury, toxic environmental exposures, and occupational and facility-associated infections.

b. Associate Director:

(1) Completing responsibilities delegated from the Hospital, as appropriate, for oversight of these policies.

c. Chief, Engineering Service:

(1) Working with contractor and VHA facility staff to coordinate and monitor an effective Construction Safety Program for projects under their direction.

(2) Completing OSHA's 30-hour Construction Safety Training and subsequently completes at least 10 hours of Construction Safety Training at least every 2 years.

(3) Supporting the periodic inspections of construction sites.

(4) Ensuring contractors comply with VA safety and health policies and procedures and contract requirements.

(5) Serving on the facility Construction Safety Committee/subcommittee to ensure contracts meet the committee's requirements.

(6) Supporting the Construction Safety Officer, Facility Safety Manager, Contracting Officer, and engineering staff in implementing the Construction Safety Program.

d. Chief, Project Planning Section:

(1) Working through safety and health staff, CORs, maintenance staff, contractors, and the Construction Safety Committee to plan, coordinate and monitor the Construction Safety Program for all projects at the facility.

(2) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

(3) Participating in monthly construction rounds of construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(4) Serving on the facility Construction Safety Committee to ensure contract requirements meet the committee's approval.

(5) Supporting the Competent Person (CP), Safety Officer, Infection Control Practitioner, Contracting Officer (CO), and engineering staff in implementation of the Construction Safety Program.

(6) Working with contracting staff to ensure competent staff is assigned as CORs to oversee work.

e. Chief, Maintenance and Operations Section:

(1) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

(2) Participate in construction rounds of in-house construction sites to ensure compliance with safety elements of the construction contract and performance of the program.

(3) Ensure that in-house work forces have necessary training and competency for tasks being performed.

f. Chief, Healthcare Technology Management:

(1) Ensuring that all construction accomplished in support of major equipment installations (as a part of the equipment purchase) comply with the site Construction Safety Program policy and procedures.

g. Contracting Officer (CO) and Contracting Officer's Representative (COR):

(1) Completing at least at least 10 hours of Construction Safety Training and completing OSHA's 30-Hour Construction Safety training. Subsequently, complete at least 10 hours of construction safety training every 2 years.

(2) Ensuring that all solicitations and contracts include the Federal Acquisition Regulation (FAR) clause found in FAR 52.236-13, Accident Prevention, and Veterans Affairs Acquisition Regulation (VAAR) clause found in VAAR 836.236-87.

(3) Designating, in writing, the Construction Safety Officer(s) (CSO) to serve as the Safety Officer for VHA contracts.

(4) Adding paragraph (f) found in FAR 52.236-13 to the basic clause if the contract will involve work of a long duration or hazardous nature, or performance on a government facility that on the advice of CSO or COR involves hazardous materials or operations that might endanger the safety of the public or government personnel or property.

(5) Ensuring that all solicitations and contracts specify that on-site general and sub-contractor's construction workers have completed at least 10 hours of Construction Safety training or the OSHA 30-hour Construction Safety training, and other relevant competency training, as determined by the CSO with input from the Multi-Disciplinary Team. The determination for other relevant competency training is based on the project hazards and complexity, Federal, and State regulations and VA requirements.

(6) Ensuring that all projects require contractor certification verifying completion of required training.

(7) Ensuring submittals for contract construction or renovation work to include the names, qualifications, and training dates for the contractor OP designated to administer the site-specific safety program, as well as the CP for other activities as required by OSHA regulation (such as scaffolds, cranes, excavations, etc.).

(8) Serving on the facility Construction Safety Committee or subcommittee to ensure contracts meet the Committee's requirements.

(9) Supporting the CSO, Facility Safety Manager, and appropriate staff in implementing the construction safety program and enforcement of the contracts.

(10) Ensuring that if contracted construction worker(s) have been determined to be at risk for transmission of tuberculosis (TB) based upon the TB section of the Infection Control Risk Assessment (to be completed by COR and approved by Infection Control prior to Contract Award), the contractor must provide written certification that all contract employees assigned to the work site have had a pre-placement tuberculin screening within 90 days prior to assignment to the worksite and been found to be with negative screening reactions.

This can be the CDC two-step skin testing or a Food and Drug Administration (FDA)-approved blood test. Contract employees manifesting positive screening reactions to the tuberculin must be examined per current CDC guidelines prior to working on VHA property.

Subsequently, if the employee is found without evidence of active (infectious) pulmonary

TB, a statement documenting examination by a physician must be on file with the employer (construction contractor) noting that the employee with a positive tuberculin screening test is without evidence of active (infectious) pulmonary TB. If the employee is found with evidence of active (infectious) pulmonary TB, the employee would require treatment with a subsequent statement as outlined in subparagraph 4q(1 1)(c) before being allowed to return to work on VHA property.

(11) Evaluating and considering past safety records of prospective contractors in awarding contracts. At a minimum, ensuring that all solicitations and contracts specify that contractors must not have more than three serious, one repeat, or one willful OSHA violation(s) in the past 3 years, or any significant environmental penalties, when contract selection is applicable at the station level.

(12) Ensuring that prior to the commencement of all projects that the contractor receive a copy of the HINES VAH Contractor Safety Disciplinary Procedures (Attachment F).

(13) The COR shall ensure proper notification to the CO if unsafe action by the contractor occurs by submitting to both the Contractor and the Contracting Officer (Attachment G) Hines VAH COR Letter of Concern for Safety Non-Compliance, in accordance with (Attachment F) HINES VAH Contractor Safety Disciplinary Procedures.

h Construction Safety Officer(s) (CS0s):

(1) Submitting project reviews of all construction projects, to include at a minimum the Infection Control Risk Assessment, Pre-Construction Risk Assessment (Attachment A), and National Environmental Protection Act Evaluation (Attachment B).

(2) Providing oversight of contract construction safety.

(3) Being knowledgeable in the general inspection of typical work sites during construction and renovation performed by contract staff and in the review of contractor safety program submittals. Note: CSO(s) do not take the place of the contractor's CP nor act on their behalf. The CSO(s) determines if the contractor is meeting VA standards and contractual requirements for safety and OSHA compliance. When these standards and contract requirements are not being met, the VA Contracting Officer's Representative (COR), CO, and CSO must take immediate action to prevent injury, exposure, noncompliance, and/or property damage.

(4) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

(5) Ensuring that the specific safety requirements for construction operations are implemented during facility projects.

(6) Serving as a member of the Multi-Disciplinary Team.

(7) Conducting periodic inspections of VHA construction sites to ensure compliance with safety elements of the established program(s); at minimum, weekly inspections are required.

(8) Monitoring and inspecting construction and renovation work sites periodically to ensure compliance with safety elements of established program(s) as noted in Attachment H, titled OSHA Required Competent Person Inspections.

(9) Maintaining competence in the general inspection of work sites during construction, renovation, and maintenance, falls under the purview of this policy.

(10) Approving corrective actions.

(11) Stopping unsafe work or activities that are non-compliant with the contract or OSHA and notifying the CO immediately.

(12) Maintaining communication with the contractor CP on questions of safety.

(13) As applicable if a Crane lift is required to complete aspects of the project then the Hines VA Hospital Planned Critical Lift Plan & Crane Permit (Attachment J) is required to be completed and approved by a member of the Safety Section prior to the Crane being allowed on campus. Once the Crane is onsite the HINES VAH Onsite Inspection Checklist for Mobile Cranes (Attachment I) shall be completed by the Construction Safety Officer prior to commencement of work.

Safety and Occupational Health Manager or designee:

(1) Completing OSHA's 30-hour Construction Safety Training and subsequently complete at least 10 hours of Construction Safety Training at least every 2 years.

(2) Ensuring that VHA policy for the Construction Safety Program is implemented within the medical center.

(3) Chairing the Construction Safety Committee.

(4) Ensuring that necessary and relevant Interim Life Safety Measures (ILSMs) are established and implemented. Conducts required additional training for compliance with identified ILSMs.

(5) Rendering technical advice and assistance as required in connection with life safety and fire protection issues during construction, project design, and development.

(6) Overseeing compliance with OSHA and other relevant construction safety regulations.

(7) Confirming that VAMC staff receives training required by this memorandum.

(8) Ensuring that the Construction Safety Program includes appropriate periodic construction site hazard surveillance.

j. Infection Control Manager or designee:

(1) Advising and/or providing recommendations on exposure mitigation and the prevention of facility associated infections in patients, staff, and visitors.

(2) Coordinating with the manager of each construction project (in-house and contract) to conduct an Infection Control Risk Assessment (ICRA) during the planning and/or design stage of the work. ICRAs must be documented in writing and focus on eliminating or minimizing the risk of infection during construction and renovation activities.

(3) Monitoring infection prevention protocols during construction activities as indicated in ICRA for that project.

k. GEMS Coordinator:

(1) Providing guidance on EPA regulations and environmental issues, as those regulations and issues directly and immediately relate to the safety during the design stage.

(2) Monitoring contractor compliance with contract specifications on EPA regulations, Attachment B — NEPA Assessment) as those regulations directly and immediately relate to the construction project, including environmental compliance, pollution prevention (Attachment D- GEMS Awareness Competent Person Training), waste management (Attachment E — Construction Project Waste Minimization Report), and permitting.

(3) Completing OSHA's 30-hour Construction Safety Training and subsequently complete 10 hours of Construction Safety Training at least every 2 years.

I. Emergency Planning Coordinator:

(1) Providing guidance on OSHA regulations as they apply to emergency planning, response and operations in construction (i.e.29 CFR 1926.35 and 29 CFR 1926.65).

(2) Monitoring contractor performance to contracted specifications on OSHA Regulations as they appear to emergency planning, response, and operations related to construction operations.

m. The Construction Safety Committee (Multi-Disciplinary Team):

(1) Determining the scope and depth of safety, infection control, emergency management, and security interventions appropriate for all construction work. The team may develop threshold criteria for each level of intervention. For instance, after review, some projects may require only Construction Safety Officer surveillance to ensure employee safety and OSHA compliance, while other projects will require all disciplines to be involved.

(2) Verifying that an Infection Control Risk Assessment (ICRA) was completed prior to construction occurring thereby mitigating the risk of transmission of Mycobacterium Tuberculosis (TB) to contracted construction workers.