Example of Infection Control Permit from COR.docx

Infection Control Permit, Class I

Location of Project: VA Western Colorado Health Care System Contractor Supervisor: Jeremy Morkus Contractor Performing Work: TBD Project: Solicitation 36C25921Q0640, Patient Lift Rail System Structural Inspections

Type A Activities, Inspection and Non-Invasive Activities.

· Removal of ceiling tiles limited to three open tiles per room.

· Inspecting, measuring, and adjusting structural supports for overhead patient lifts.

Unoccupied Low, Medium or High-Risk Areas

· Community Living Center Patient Rooms

· ICU Patient Rooms

· Med/Surg Patient rooms

· Rehabilitation gymnasium

· Ambulatory surgery rooms

· Similar rooms with overhead patient lifts

Class I Infection Control Precautions

· Execute work by methods to minimize dust dispersal from minor flooring or surface disruptions.

· Close the room door for the duration of the inspection.

· Before beginning work, cover all equipment, furniture, casework, or similar items with single use plastic

· Replace a ceiling tiles once access is no longer required

· Remove plastic coverings in a manner that does not disperse any dust on the plastic

· Clean up any dust that may have been generated with HEPA filtered vacuum, damp mop, or sanitizing wipe.

· EMS (VA staff) to preform final clean prior to patient returning to room

Permit Authorized by (signature & date): ________________________________________________________________ Authorized Signers: Elizabeth Meyer / Anna Crickmer

Permit Authorized by (signature & date): ________________________________________________________________ Authorized Signers: Brian Saunders / Brad Rough / Terri Hart / Andria Dutcher

Permit Authorized by (signature & date): ________________________________________________________________ Authorized Signers: Jose Trujillo / Christie McVay