Section_J_Attachment_1.5_Infection_Control_Permit.pdf

Infection Control Construction Form Permit# 0101

Location of Construction: Yakama Service Unit Pro_ject Start Date:

Pro_ject Coordinator: John Pulsipher Estimated Duration: 120 days Contractor Performine Work: Permit Expiration date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK

X TY PE A: Inspection, non-invas ive acti vity. X GROUP I : Low Risk

X TY PE B: Small scale, short du ration, moderate to high levels. X GROUP 2: Medium Risk

TY PE C: Activity generates moderate X to high levels of dust, required greater than one X GROUP 3: Medium/High Risk work shift fo r completion.

TYPED: Major duration and X construction activities GROU P 4: Highest Risk req uiring consecuti ve work X shifts.

I. Execute work by methods to minimize raising dust from construction operations.

CLASS I 2. Immediately replace any ceiling tile displaced for visual inspection.

3. Minor demolition for remodeling.

I. Provides active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting.

3. Seal unused doors with duct tape.

4. Block off and seal ai r vents.

CLASS II 5. Wipe surfaces wi th dis infectant.

6. Contain construction waste before transport in tightl y covered containers.

7. Wet mop and/or vacuum with HEPA fi ltered vacuum before leaving work area.

8. Place just mat at entrance and exit of work area.

I. Obtain infection control forn1 before construction begins.

2. Isolate HVAC systems in area where work is being done to prevent contamination of the duct system.

CLASS Ill 3. Complete all crit ical barriers before construction begins.

4. Maintain negative ai r pressure within work site util izing HEPA equipped air filtration units or exhaust outside.

5. Do not remove barriers from work area until complete project is thoroughly cleaned by Environmental Services Dept.

6. Vacuum work wi th HEPA filtered vacuums.

Date 7. Wet mop with disinfectant.

3' /1~/lfj 8. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

9. Contain construction waste before transport in tightly covered containers.

IO.Cover transport receptacles or carts. Tape covering.

11 Remove or isolate HVAC system in areas where work is being performed .

I. Obtain infection control fo rm before construction begins.

2. Isolate HVAC systems in area where work is being done to prevent contamination of the duct system.

3. Complete all criti cal barriers before construction begins.

CLASS IV 4. Maintain negative air pressure with in work site util izing HEPA equipped air filtration units or exhaust outside.

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

6. Construct barriers so staff may be vacuumed using a HEPA vacuum cleaner before leaving work si te or they can wear cloth or paper coveralls that are removed each time they leave the work site.

7. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker

Date exits the work area.

8. Do not remove barriers from work area until completed project is inspected by the owner' s Safety Department and

In fec tion Control Department and thoroughly cleansed by the owner's Environmental Services Department.

9. Vacuum work area with HEPA fi ltered vacuums.

I 0. Wet mop area with disinfectant.

Initial I I .Remove barrier materials careful ly to minimize spreading of dirt and debri s associated with construction.

12.Contain construction waste before transport in tightly covered containers.

13 .Cover transport receptacles or carts. Tape covering.

14. Isolate HVAC svstem in areas where work is being done.

Additional Requirements:

'8' )5/1& ()A~ Date/Initials:

Date/Initials: Exceptions/Additions to this form are noted by attached

' ( memoranda.

Form Requested by: Forni Authorized by:

Date: Date: