36C24218B0068-008.pdf

Project Title: Project #:

Location: Project COR:

Start Date: Phone:

Step 1 - GENERAL SAFETY

GUIDELINE

GUIDE

MET AREA(s)

IMPACTED CONTROL ACTIVITIES NEEDED

Y N

AIR QUALITY: Will there be any compromise to the quality of building air?

Asbestos

Lead

Dust

Other hazardous chemicals

VENTILATION: Will there be any compromise to the building ventilation or air handling systems?

MOISTURE & TEMPERATURE: Are there any anticipated moisture or temperature concerns?

UTILITIES: Are there any anticipated utility disruptions?

• Communication/Telephone

• Electrical Systems

• Security Systems

• Steam Systems

• HVAC

• Medical Gases/Vacuum

• Natural Gas

• Sewer/Sanitary

• Water

• OTHER:

NOISE: Will there be any unusually loud or high-pitched noise levels anticipated?

VIBRATION: Will vibration levels be excessive to effect the operation of hospital type equipment or machinery?

EMERGENCY MANAGEMENT: Does construction present any conflicts or challenges to the facility EM Plan?

SECURITY: Will the construction anticipate general security concerns?

OTHER ANTICIPATED HAZARDS NOT LISTED

Off-tour Construction necessary?

Permit Required Confined Space (PRCS) Entry necessary?

Welding, cutting or brazing necessary that requires Hot Work permit?

Potential exposure to BBP or other infectious agents?

Excavation of soil?

Work on live electrical systems or hot taps?

Work on energized non-electrical systems?

Lift of materials with crane?

NOTE: If a Guideline is not met, additional actions are required based upon the risk assessment. If required, additional safety actions shall be performed and implemented PRIOR to start of work involving locations affected by the assessment.

Step 2 – LIFE SAFETY

Requirement Met Actions Required

ILSM

Req’d

Y N Y N

EXIT ROUTES (MEANS OF EGRESS COMPONENTS)

Exit from occupied areas will remain unchanged?

Exit stairs will remain unobstructed and fire separated?

FIRE PROTECTION SYSTEMS:

Fire alarm devices will remain functional & in-service throughout construction?

Sprinkler systems will remain functional & in-service throughout construction?

Fire Suppression systems will remain functional & in-service throughout construction?

FDC’s will remain functional & unobstructed?

SMOKE AND FIRE BARRIERS:

All fire and smoke barriers will remain intact throughout?

All vertical openings will remain intact throughout?

CONSTRUCTION SPACES:

Will be separated by non-combustible, smoke tight partitions?

Will be separated by a fire rated barrier?

At least one accessible and unobstructed exit is provided?

Excessive distance to exits?

Hazardous area protected?

GENERAL:

Access for emergency responders will remain unchanged?

Load bearing building assemblies are maintained throughout?

NOTE: All required ILSM’s shall be in accordance with the facility ILSM Policy and developed separate from this assessment. If required, ILSM’s shall be performed and implemented PRIOR to start of work involving locations affected by the ILSM.

SAFETY NARRATIVE:

Signature of Safety Officer Date

Signature of Engineering COR Date

Signature of Project Supervisor Date