3-ILSM.pdf

INTERIM LIFE SAFETY MEASURES PLAN

PRELIMINARY ASSESSMENT

Area Name

Project Title::

Current Date:

Project and Contract Number :

Description of Project, Situation, and Condition being evaluated:

Departments and/or buildings that will be, or are affected by Project, Situation, or Condition:

Time frame during which Project, Situation, or Condition exists or will exist (give dates):

Life Safety features which are affected by Project, Situation, or Condition (list below)

1.

2.

3.

4.

Is there potential for any of these conditions to impact the life safety of patients, visitors, or staff? Yes/No _____

If No, explain why not?____________________________________________________________

Based on these findings, does this project, situation, or condition warrant the implementation of ILSM? Yes/No _____

Signature of Individual Completing form Date

February 1997 (24−9) 13 TN - ___

INTERIM LIFE SAFETY MEASURES PLAN

IDENTIFIED LIFE SAFETY DEFICIENCIES

Project Title: __________________________________________ Project and Contract Number: ___________________

STATUS

YES NO N/A

1. Have alternative exits been designated as a result of the project, condition, or situation? Yes/No ____ Specify Locations:

2. Are exit routes inspected daily to ensure they are free and unobstructed? Yes/No ____ [Complete attachment C to document monitor inspections]

3. Has training been provided to personnel on the alternative exits ?Yes/No ____ [Use attachment G to document training]

4. Does the project, condition, or situation interfere with the accessibility to and from the emergency room by emergency forces, the public, and/or staff? Yes/No ____

If Yes Specify How

[Complete attachment D to document monitoring]

5. Does the project, condition, or situation impair the existing fire alarm, detection, and/or suppression system in any way? Yes/No ____

If Yes Specify how:

6. Has a temporary, yet equivalent, system been provided? Yes/No ____

If Yes Specify type:

7. Document the dates of the inspection and testing of the temporary system (must be done monthly):

8. Has temporary construction partitions been constructed that are smoke tight and are of noncombustible or limited combustible material? Yes/No ____

If Yes Specify Construction material and locations:

February 1997 (24−9) 14 TN - ___

February 1997 (24−9) 15 TN - ___

STATUS

YES NO N/A

9.

Has additional fire-fighting equipment been provided?

If Yes Specify type, number, and locations:

Yes/No ____

10. Has training on the use of fire-fighting equipment been provided?

[Complete attachment G to document training]

Yes/No ____

11. Has smoking been prohibited in and adjacent to the project? Yes/No ____

12. Are storage, housekeeping, and debris removal practices monitored to reduce the combustible and flammable fire load? Yes/No ____

[Complete attachment E to document monitoring]

13.. Are a minimum of two drills per quarter per shift currently being conducted? Yes/No ____

14. List the dates of drills conducted:

QUARTERS SHIFTS

[List Months Covered in Spaces Below]

FIRST SECOND THIRD

9. Has hazard surveillance been increased to monitor buildings, grounds, and equipment with special attention given to excavations, construction areas, construction storage, and field offices? Yes/No ____

[Complete attachment F to document monitoring]

10. Have personnel been trained when structural and compartmentation features of fire protection are

February 1997 (24−9) 16 TN - ___ compromised? Yes/No ____

[Complete attachment G to document training]

11. Are organization wide safety education programs being conducted to ensure awareness of any LSC deficiency, construction hazard and these ILSM measures? Yes/No ____

[Complete attachment G to document training]