ICRA 2.0 ICRA. Permit.pdf

©2022. American Society for Health Care Engineering of the American Hospital Association

ICRA 2.0 Infection Control Risk Assessment and Permit

Project Name:

ICRA Number: Requested by

Location of Work Activity Project Start Date Estimated Duration Completion Date

Foreman/Supervisor Phone Contractor Performing Work Phone

Approving Authority Phone Please note that the above signature is approval of the work activity as described and assessed documented here.

Should the scope of work change or the discovery of additional toxic or biological substances.

STOP WORK and seek additional approval and guidance before proceeding.

1. Type of Activity Explain this reasoning for this assessment Type A: Non-invasive Type B: Small-scale, short duration Type C: Large-scale, longer duration Type D: Major demolition, construction

2. Patient Risk Area Describe key patient risks Low: Non-patient care areas Medium: Patient care support areas High: Patient care areas Highest: Invasive, sterile or highly compromised care

3. Class of Precautions Type A TYPE B TYPE C TYPE D

Low I II II III Medium I II III IV

High I III IV V Highest III IV V V

4. Surrounding Area

Unit Below: Above: Lateral: Behind: In Front:

Risk group Contact

Phone Controls Noise

Vibration Dust Ventilation Pressurization

Noise Vibration Dust Ventilation Pressurization

Noise Vibration Dust Ventilation Pressurization

Noise Vibration Dust Ventilation Pressurization

Noise Vibration Dust Ventilation Pressurization

Systems impacted:

Data Mechanical Med Gas Hot/Cold Water Other

Data Mechanical Med Gas Hot/Cold Water Other

Data Mechanical Med Gas Hot/Cold Water Other

Data Mechanical Med Gas Hot/Cold Water Other

Data Mechanical Med Gas Hot/Cold Water Other

Were there discoveries in surrounding areas that would serve as cause to increase the class of precautions and necessitate additional controls? If so, please summarize.

©2022. American Society for Health Care Engineering of the American Hospital Association

5. Detailed Plan of ICRA Controls for this Work Final Class of Precautions being applied I II III IV V

Controls required for this project Specifications/ Materials Verification method and frequency

Exceptions/Additions to this permit Date and Initials are noted by attached memoranda

Initials Date

Permit Request By Date

Permit Authorized By Date

Approval Signature

©2022 The American Society for Health Care Engineering of the American Hospital Association Disclaimer: This document is provided by ASHE as a service to its members. The information provided may not apply to a reader’s specific situation and is not a substitute for application of the reader’s own independent judgment or the advice of a competent professional. ASHE does not make any guaranty or warranty as to the accuracy or completeness of any information contained in this document. ASHE and the authors disclaim liability for personal injury, property damage, or other damages of any kind, whether special, indirect, consequential, or compensatory, that may result directly or indirectly from use of or reliance on this document.