VA 01 00 00 General Requirements - Attachment 5a and 5b.pdf
PDF 699 KB Posted
- Solicitation number
- 36C24822R0173
About this file
This document contains a contractor work plan and peer review request form along with information for a federal contract opportunity to replace the Cardiac Cath Lab 1 at the James A. Haley VA Medical Center in Tampa, Florida. The contractor work plan form requests details on the duration, location, description of work, tools and equipment needed, personal protective equipment, names of employees, work procedures before, during and after, and notifications to the COR and general contractor. The peer review form requires signatures from various facility staff approving the work. The federal contract opportunity is solicitation number 36C24822R0173 to replace the cardiac cath lab as project number 673-CSI-127 through the Department of Veterans Affairs Veterans Health Administration VISN 8. No response date or award date is included.
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Text version
Attachments 5a & 5b
Contractor Work Plan & Peer Review
SECTION 01 00 00
GENERAL REQUIREMENTS
ATTACHMENT #5 - A
CONTRACTOR WORK PLAN / PEER REVIEW REQUEST
PROJECT No. & TITLE:
START DATE: Su M T W Th F Sa @ TIME:
END DATE: Su M T W Th F Sa @ TIME:
ESTIMATED DURATION OF WORK: HOURS
LOCATION OF WORK:
DESCRIPTION OF WORK:
TOOLS & EQUIPMENT TO PERFORM WORK:
PERSONNAL PROTECTIVE EQUIPMENT FOR WORK:
NAME(S) OF EMPLOYEE(S) PERFORMING WORK:
SUPERVISOR / WORK LEADER NAME (PRINTED):
SUPERVISOR / WORK LEADER SIGNATURE:
DATE:
Section 01 00 00, General Requirements – Attachment #5 - A
Revised March 2018
DATE:
DATE:
PROCEEDURE(S):
All maintenance and repair work must have a written procedure prepared by the maintenance person performing the task.
BEFORE:
DURING:
AFTER:
Section 01 00 00, General Requirements – Attachment #5 - A
Revised Mar 2018
DATE AND TIME COR NOTIFIED:
GENERAL CONTRACTOR’S NOTIFYING PERSON:
NOTIFYING PERSON’S SIGNATURE:
GENERAL CONTRACTOR COMPANY:
PHONE NUMBER(S) –
OFFICE:
CELL:
Section 01 00 00, General Requirements – Attachment #5 - A
Revised March 2018
SECTION 01 00 00
GENERAL REQUIREMENTS
PEER REVIEW #5 – B
PROJECT No. & TITLE:
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
* - Designates signature required.
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
Section 01 00 00, General Requirements – Attachment #5 - B
Revised March 2018
*Logistics
*SPD/SPS
*AFGE
*NNU
*POLICE
Power Plant
VHATAMHaleM Sticky Note Accepted set by VHATAMHaleM
| DateCOTR FMS: |
| DateElec Supv FMS: |
| DateAC Supv FMS: |
| DatePlumb Supv FMS: |
| DateControls FMS: |
| DateMO Supv FMS: |
| DateProjects Supv FMS: |
| DateSafety FMS: |
| DateBioMed FMS: |
| DateChief FMS: |
| DateInfect Ctrl MED: |
| NameRow12: |
| DateRow12: |
| NameRow13: |
| DateRow13: |
| NameRow14: |
| DateRow14: |
| NameRow15: |
| DateRow15: |
| NameRow16: |
| DateRow16: |
| NameRow17: |
| DateRow17: |
| Contract Information: |
| Group25: Off |
| Group26: Off |
| Duration - #5A: |
| Description of Work - #5A: |
| Tools and Equipment - #5A: |
| Personal Protective Equipment - #5A: |
| Employee Names - #5A: |
| Procedure - #5A: |
| Before Work - #5A: |
| During Work - #5A: |
| Location of Work - #5A: |
| After Work - #5A: |
| Supvr Sig Date - #5A: |
| Contractor Notifier Name - #5A: |
| Supervisor or Work Leader Name - #5A: |
| GC Company Name - #5A: |
| COTR Notified Date - #5A: |
| Notifier Office Phone - #5A: |
| Notifier Cell Phone - #5A: |
| Project # and Title - #5A: |
| NameCOTR FMS: |
| NameElec Supv FMS: |
| NameAC Supv FMS: |
| NamePlumb Supv FMS: |
| NameControls FMS: |
| NameMO Supv FMS: |
| NameProjects Supv FMS: |
| NameSafety FMS: |
| NameBioMed FMS: |
| NameChief FMS: |
| NameImfect Ctrl MED: |
| 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 |
| Reset - #5A: |
| Print - #5A: |
| Start Time - #5A: |
| End Time - #5A: |
| End Date - #5A: |
| Start Date - #5A: |
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