VA CWM UTILITY SHUTDOWN REQUEST 2025 fillable form.pdf

VA CWM UTILITY SHUTDOWN REQUEST

Project Number: Company/Name:

Shutdown POC: POC Phone Number:

Requested Shutdown Date(s):

Expected Start Time:

Expected Stop Time:

Location of Shutdown:

Location of Work:

Location of

LOTO:

Competent Person(s):

PPE

Required:

Reason for Shutdown:

Description of Work:

All Building(s)/Area(s) Impacted (include downstream and upstream systems affected):

SERVICES AFFECTED BY SHUTDOWN

Service(s) being shut down during the requested work period: ✔ Service(s) affected during the requested work period: X ☐ Steam ☐ Domestic Cold Water ☐ Chilled Water ☐ Fire Alarm ☐ IT ☐ HVAC ☐ Domestic Hot Water ☐ Sanitary System ☐ Sprinkler System ☐ Other:

☐ Normal Power ☐ Heating Hot Water ☐ Nurse Call ☐ Emergency Power

WRITTEN NOTIFCATION REQUIRED

• Requests for utility shutdown must be conducted per 01 00 00 GENERAL REQUIREMENTS. Type of shutdown (major/minor) are the discretion of COR.

• Minor shutdowns require a 7-calendar day notification.

• Major shutdowns require a 21-calendar day notification. Major shutdowns are any interruptions that affect Medical Center operations.

• All Fire Alarm and Sprinkler shutdowns and outages require coordination with VA Fire Alarm Technician.

• All LOTO (Lock Out Tag Out) equipment and mandatory PPE must be on site and is required to shut down utilities. Failure to have proper

PPE and equipment will result in the shutdown being cancelled.

Requestor (Signature and Date):

VA ONLY-COR COMMENTS AND CONSIDERATIONS

Is shop support required for the shutdown? (i.e. investigating systems) YES NO If yes, specify support needed for shutdown:

Additional Comments:

COR Acknowledged (Signature and Date): APPROVED DENIED

VA ONLY-OPERATIONS AND MAINTENANCE

Is shop presence support required for the shutdown? YES NO Comments:

O&M Shop Acknowledged (Signature and Date):

VA CWM UTILITY SHUTDOWN REQUEST INSTRUCTIONS

CONTRACTORS RESPONIBILTIES

1. Requests need to be made in enough advance for investigation of affected systems by VA.

2. VA M&O shops require 72-hour notice from VA CORs for all shutdowns.

3. The below needs to be provided for the corresponding section:

• Shutdown POC/POC Phone Number: Provide the person onsite for the shutdown that will be coordinating all work and communicating with VA and appropriate parties. This contact will be provided to appropriate VA parties.

• Shutdown Date and Times: These times are a reflection of the time the utility will be shutdown which may differ from the overall time for the rest of the work to be completed.

• Location of Shutdown: Building(s), Floor(s), and Room Numbers(s), directly affected by the shutdown.

• Location of Work: Building(s), Floor(s), and Room Numbers(s) where the work is being performed.

• Location of LOTO: Include a Primary Panel Number(s)/Circuit Number(s) or Pipe(s) Tagged.

• Competent Person(s): Provide the name of the CP that will be performing the shutdown & LOTO for the shutdown.

• PPE Required: List all PPE required for shutdown. Failure to have proper PPE and equipment will result in the shutdown being cancelled.

• Reason for Shutdown: Specify work being performed that requires the shutdown.

• Description of Work: Provide all work to be completed during the shutdown. Ensure required permits are obtained as applicable.

• Impacted Area(s): All impacted/affected areas are determined by investigating panel schedules, tracing down stream piping, etc. VA COR assistance may be necessary to determine impacts, so it is recommended to involve the COR as early as possible to investigate the shutdown. Submit a photo of all panels and panel schedules affected by the shut down with this request form.

• Services Affected by Shutdown: Mark both the utility being shut down as well as utilities impacted by the shutdown.

(i.e. electrical shut downs may affect HVAC, IT Systems, Nurse Call)

• A copy of the fully executed request form is required for shutdown.

VA (COR) RESPONIBILTIES

1. Review request for accuracy. In the comments, specify whether an investigation will need to occur to ensure all interrupted services are listed. Email request to Greg and applicable M&O Shop Supervisor(s).

2. Notify the M&O Shops and Projects Team of shutdown to avoid conflicting shutdowns or interrupt work on other projects.

3. Review shutdown with Shops. Confirm what systems will be affected and ensure critical functions (phone, medication fridges, etc.) are not interrupted or have a contingency plan.

4. Communicate with affected Supervisors and Staff to ensure Medical Center operations can be maintained. Address concerns as necessary.

5. Meet with the Contractor to confirm shutdown schedule, duration and ensure VA is prepared for additional investigation if required.

6. Ensure that adequate temporary measures are in place that Medical Center Operations remain unaffected/mitigated.

7. Ensure if shop presence is required that shop personnel is available and present for shutdown.

8. Once request has been signed by all parties, provide general notification including End Users, Engineering, Police, and

Greg. Return completed form to the Contractor.

M&O (SHOPS) RESPONIBILTIES

1. Review request for accuracy-ensure all impacted systems are listed. If impacted systems are missing, notify COR.

2. Report any known issues to COR, ensure to provide follow-up tasks/actions if needed. (i.e. checking breakers after shutdown, checking specific affected systems etc.)

3. If shop support is required for shutdown, specify in the “Comments” section. Notify COR to coordinate. Communicate all

Shop requirements to COR.

4. Return completed form to COR.