S02 - VA Form 10101 Contractor Production Report.pdf
PDF 87 KB Posted
- Attached to
- Z2DA--537-21-113 Remodel Blood Draw
- Solicitation number
- 36C25223B0021
About this file
This document contains a VA Form 10101 Contractor Production Report template and details of a related federal contract opportunity for remodeling a blood draw facility at a Veterans Affairs medical center. The Contractor Production Report is a form used by construction contractors to record daily progress on VA construction projects, including weather conditions, work activities, staffing levels, safety inspections, materials received, and equipment used. It requires signatures from the contractor and superintendent.
The related federal contract opportunity is a solicitation to remodel a blood draw facility at the Jesse Brown VA Medical Center in Chicago. It is identified as solicitation number 36C25223B0021 and is an opportunity within the Department of Veterans Affairs Veterans Health Administration VISN 12. The response is due by August 21, 2021.
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Text version
OMB No.: 2900-0208 Exp. Date: Mar 31. 2022 Respondent Burden: 24 Minutes
CONTRACTOR PRODUCTION REPORT
(Attach additional sheets if necessary)
DATE
CONTRACT NUMBER TITLE AND LOCATION (Title and Location of Construction Contract) REPORT NUMBER
CONTRACTOR SUPERINTENDENT
AM WEATHER (Weather data, include precipitation & winds) PM WEATHER (Weather data, include precipitation & winds) MAX TEMP (F) MIN TEMP (F)
WORK PERFORMED TODAY
SCHEDULE ACTIVITY NO. WORK LOCATION AND DESCRIPTION EMPLOYER NUMBER TRADE HOURS
JOB SAFETY
WAS A JOB SAFETY MEETING HELD THIS DATE?
(If YES, attach copy of the meeting minutes) YES NO
WERE THERE ANY LOST TIME ACCIDENTS THIS DATE?
(If YES, attach copy of completed OSHA report) YES NO
WAS CRANE/MANLIFT/TRENCHING/SCAFFOLD/HV ELEC/HIGH WORK/HAZMAT
WORK DONE? (If YES, attach statement or checklist showing inspection performed)
YES NO
TOTAL WORK HOURS ON JOB SITE, THIS
DATE, INCL CON'T SHEETS
CUMULATIVE TOTAL OF WORK HOURS
FROM PREVIOUS REPORT
TOTAL WORK HOURS FROM START OF
CONSTRUCTION
SCHEDULE
ACTIVITY NO.
LIST ANY SAFETY ACTION TAKEN TODAY/SAFETY
INSPECTION CONDUCTED
(Include any safety topic covered during the safety meeting)
SAFETY REQUIREMENTS
HAVE BEEN MET
EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (Indicate a schedule activity number) SCHEDULE ACTIVITY NO. SUBMITTAL NUMBER DESCRIPTION OF EQUIPMENT/MATERIAL RECEIVED
CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY, INDICATE
HOURS USED AND SCHEDULE ACTIVITY NUMBER
SCHEDULE ACTIVITY NO. OWNER DESCRIPTION OF CONSTRUCTION EQUIPMENT USED TODAY (Include Make and Model)
SCHEDULE ACTIVITY NO. REMARKS
CONTRACTOR/SUPERINTENDENT DATE REPORT PREPARED
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to , a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will be average 24 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. If your firm does not already have a similar form, this is used to record the data necessary to assure the contractor provides sufficient labor and materials to accomplish the contract work. This form or a similar document is required to guarantee the performance of the work necessary to complete the project.
VA FORM
JUL 2018 10101
OMB No.: 2900-0208 Exp. Date: Mar 31. 2022 Respondent Burden: 24 Minutes O M B No.: 2900-0208 Exp. Date: Mar 31. 2022 Respondent Burden: 24 Minutes Department of Veterans Affairs LOGO
CONTRACTOR PRODUCTION REPORT
(Attach additional sheets if necessary)
CONTRACTOR PRODUCTION REPORT
(Attach additional sheets if necessary)
DATE
CONTRACT NUMBER
TITLE AND LOCATION (Title and Location of Construction Contract)
REPORT NUMBER
CONTRACTOR
SUPERINTENDENT
AM WEATHER (Weather data, include precipitation & winds) PM WEATHER (Weather data, include precipitation & winds)
MAX TEMP (F)
MIN TEMP (F)
WORK PERFORMED TODAY
SCHEDULE ACTIVITY NO.
WORK LOCATION AND DESCRIPTION
EMPLOYER
NUMBER
TRADE
HOURS
JOB SAFETY
WAS A JOB SAFETY MEETING HELD THIS DATE?
(If YES, attach copy of the meeting minutes)
WERE THERE ANY LOST TIME ACCIDENTS THIS DATE?
(If YES, attach copy of completed OSHA report)
WAS CRANE/MANLIFT/TRENCHING/SCAFFOLD/HV ELEC/HIGH WORK/HAZMAT
WORK DONE? (If YES, attach statement or checklist showing inspection performed)
TOTAL WORK HOURS ON JOB SITE, THIS
DATE, INCL CON'T SHEETS
CUMULATIVE TOTAL OF WORK HOURS
FROM PREVIOUS REPORT
TOTAL WORK HOURS FROM START OF
CONSTRUCTION
SCHEDULE
ACTIVITY NO.
LIST ANY SAFETY ACTION TAKEN TODAY/SAFETY
INSPECTION CONDUCTED
(Include any safety topic covered during the safety meeting) EQUIPMENT/MATERIAL RECEIVED TODAY TO BE INCORPORATED IN JOB (Indicate a schedule activity number)
SCHEDULE ACTIVITY NO.
SUBMITTAL NUMBER
DESCRIPTION OF EQUIPMENT/MATERIAL RECEIVED
CONSTRUCTION AND PLANT EQUIPMENT ON JOB SITE TODAY, INDICATE
HOURS USED AND SCHEDULE ACTIVITY NUMBER
SCHEDULE ACTIVITY NO.
OWNER
DESCRIPTION OF CONSTRUCTION EQUIPMENT USED TODAY (Include Make and Model)
SCHEDULE ACTIVITY NO.
REMARKS
CONTRACTOR/SUPERINTENDENT
DATE REPORT PREPARED
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to , a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who must complete this form will be average 24 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. If your firm does not already have a similar form, this is used to record the data necessary to assure the contractor provides sufficient labor and materials to accomplish the contract work. This form or a similar document is required to guarantee the performance of the work necessary to complete the project.
VA FORMJUL 2018
V A Form 1 0 1 0 1, JULY 2018 10101 C:\Program Files\Adobe\Form Designer\Forms\Adobe.xft\VA3918.xft David Wachter April 2015 5.0
OA&MM
VA3918
{CF3222A7-20FA-11D4-ABC1-00D0B71D6ABB}
PDFForms.xml Spelling Checker;{224F7DEA-B7C1-11D3-AB40-00902712A5C9};PLSSpeller.cab Intra-Agency Transfer Request David Wachter VA Form 3918
JULY 2018
10101, CONTRACTOR, PRODUCTION, CONSTRUCTION
Missie Vaccaro-Palomaki VA Form 10101, CONTRACTOR PRODUCTION REPORT Rafael Taylor/Sterai Payne/Karen Bruce (003A2A)
DATE REPORT PREPARED
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to , a collection of information unless it displays a valid O M B number. We anticipate that the time expended by all individuals who must complete this form will be average 24 minutes. This includes the time it will take to read instructions, gather the necessary facts and fill out the form. If your firm does not already have a similar form, this is used to record the data necessary to assure the contractor provides sufficient labor and materials to accomplish the contract work. This form or a similar document is required to guarantee the performance of the work necessary to complete the project.:
| CONTRACTOR/SUPERINTENDENT: |
| SCHEDULE ACTIVITY NUMBER, line 4 of 4: |
| OWNER, line 4 of 4: |
| REMARKS, line 4 of 4: |
| SCHEDULE ACTIVITY NUMBER, LINE 4 OF 5: |
| WORK LOCATION AND DESCRIPTION, LINE 4 OF 5: |
| HOURS, LINE 4 OF 5: |
| SCHEDULE ACTIVITY NUMBER, LINE 5 OF 5: |
| WORK LOCATION AND DESCRIPTION, LINE 5 OF 5: |
| HOURS, LINE 5 OF 5: |
| SAFETY REQUIREMENTS |
HAVE BEEN MET "YES" CHECK BOX.: 0
SAFETY REQUIREMENTS
HAVE BEEN MET "YES" CHECK BOX.: 0
SAFETY REQUIREMENTS
HAVE BEEN MET "YES" CHECK BOX.: 0
SAFETY REQUIREMENTS
HAVE BEEN MET "YES" CHECK BOX.: 0
| "NO" CHECK BOX.: 0 |
| "NO" CHECK BOX.: 0 |
| "NO" CHECK BOX.: 0 |
| TOTAL WORK HOURS ON JOB SITE, THIS |
DATE, INCL CON'T SHEETS:
CUMULATIVE TOTAL OF WORK HOURS
FROM PREVIOUS REPORT:
TOTAL WORK HOURS FROM START OF
CONSTRUCTION (Auto calculated field):
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