36C26018Q9659-003.pdf

Pre-Construction Risk Assessment

Infection Control / Safety Construction Permit

Project Number:

Yes No

Yes No

Location of Construction:

Project COR:

Project Start Date:

If so, these departments must be notified.

The following must be addressed and put in place prior to any construction activities:

• Separation wall must be constructed prior to project beginning, or secure an existing barrier. Put signs on doors into construction area “Construction area – Do Not Enter”.

• Fire protection systems must remain intact.

• Provide extra fire extinguishers in the work areas.

• Maintain exit lights in work area.

• Maintain negative air in construction area (24/7) through duration of project when necessary.

• There cannot be any return air from within the construction area to the rest of the building.

• Ensure public exiting does not go through the construction area.

• Maintain daily logs, daily hot work permits, daily confined entry permit, etc.

• Place sticky mats at doors exiting construction area.

• All debris must be removed by covered cart on a daily basis.

• Maintain clean and orderly work area on a daily basis.

How are you going to reduce the noise or vibration to an acceptable level?

Will there be a Confined Space Entry required on this project? If so, MCM 138-29, Confined Space Entry policy must be followed.

Will there be hot work on this project? If so, FMS Memorandum FMS -14, Hot Work Operations must be followed. A hot work permit must be approved by Safety Manager or designated Competent Person (CP) for the project and posted at the job site. All hot work must have a fire watch assigned to each area while the hot work is being performed.

Is asbestos abatement required on this job? If so, the MCM 00-19, Asbestos control Program and MCM 138-13, Asbestos Management Plan must be followed. Notify Safety, the Industrial Hygienist, the AFGE representative, and the Maintenance Supervisor prior to abatement.

Are fumes and odors present? If so, how will fumes and odors be controlled? MSDS sheets are required.

Will there be noise or vibration generated that will impact a department adjacent to, above, or below the construction zone?

Are any of the following environmental hazards present?

Contractor:

Superintendent:

Estimated Duration:

Permit Expire Date:

Telephone:

Description of Project:

Will work be done in a sterile area? If so, how are you going to maintain sterile atmosphere in work area and access to and from work area?

Is supply duct to area closed? Is HEPA filtration unit in place and functioning?

Yes No

Yes No

NoYes

Are Emergency Procedures in place and posted on each job site for accidental events that could greatly impact Patient Care or Life Safety to the facility? If NO, explain.

Fire Alarm (If out for more than 4 hours, Interim Life Safety Measures must be implemented). Any impact that impacts major breaches in a fire or smoke wall.

HVAC

Sewage

Oxygen

Domestic Water

Electrical

Negative airflow ventilation and filtration in place and assessed for effectiveness.

Will dust be generated during this project? If yes explain location of and plan for interim dust barriers.

Will any of the following systems be out of service at any time during the project? If so, Interim Life Safety

Measures must be implemented.

Air Quality and Infection Control: The construction activity types are defined by the amount of dust that is generated, the duration of the activity, and the amount of shared HVAC systems. The Maintenance

Supervisor or COR shall direct questions to Infection Control and/or Safety Manager.

Additional Safety Concerns:

Will debris removal be necessary? If yes, explain the plan for debris removal and dust control.

Will construction project affect traffic in the area? If yes explain actions taken to minimize problems.

Will construction affect exit routes from occupied areas adjacent to the construction site?

Explain, may require Interim Life Safety Measures.

Sprinkler (If out for more than 4 hours, Interim Life Safety Measures must be implemented).

TYPE “C”

II

III

III/IV

Access to chase spaces. Installation of telephone and computer cabling.

Type C: Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components and assemblies or new construction.

Small scale removal of ceiling tiles for visual inspection or minor installation.

TYPE A: Inspections and Non-Invasive Activities or Small Scale, Short Duration Activities.

Yes No

Yes No

Yes No

Type B: Small Scale, Short Duration Activities that create minimal dust.

Wall covering, electrical trim work, minor plumbing, and activities that do not generate dust or require cutting of walls – describe work to be done.

Painting (but not sanding).

Sanding or cutting of walls or ceiling where dust migration can be controlled.

I

ACT, CLC

Radiology/Nuclear Med Respiratory Therapy Physical Therapy Outpatient Clinics Pharmacy Food Service

Removal of floor coverings ceiling tiles casework. Describe:

Sanding of walls for painting or wall covering.

Office areas Lobbies Public corridors Elevators Canteen Retail Store

Group 1

Lowest

Group 2

Medium

I

II

I

IIIGroup 3

CLASS I

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

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

CLASS II

1. Notify staff in the immediate area.

2. Provide active means to prevent air-borne dust from dispersing in atmosphere.

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

4. Seal unused doors with duct tape.

5. Block off and seal air vents.

6. Place dust mat at entrance/exit of work area.

7. Contain construction waste before and during transport in tightly covered containers.

8. Upon completion, wipe work surfaces with disinfectant, wet mop and/or vacuum with HEPA filtered vacuum before leaving work area; and remove isolation of HVAC system.

Group 2

Activity where high levels of dust are generated and cannot be completed with a single work shift.

Major cabling activities.

Minor ductwork or electrical work above ceilings.

New wall construction.

Cutting of walls or ceiling. Describe:

Group 3

High

Ambulatory Surgery Intensive Care Units Laboratories SPD Storage/Sterilization TB Negative Pressure Isolation Rooms

TYPE “B”

I

CONSTRUCTION ACTIVITY TYPE →

INFECTION CONTROL RISK GROUP ↓

Group 1

Contact Infection Control for assessment of any area not listed above.

TYPE “A”

DATE: DATE:DATE:

Project COR:

Chief, Facilities

Management Service

Approval:

Safety Manager

Approval:

Infection Prevention Representative

Approval:

CLASS III

1. Obtain Safety/Infection Control concurrence before construction begins.

2. Complete all critical barriers, i.e. sheetrock, fire rated plywood or plastic, to seal from non-work area before construction begins.

3. Isolate HVAC system in area and maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before and during transport in tightly covered containers.

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

6. Place dust mat at entrance and exit of work area. Replace as needed. Personnel required to ensure shoes are not tracking when leaving the work site.

7. Upon completion, do not remove barriers from work area until completed project is thoroughly cleaned by FMS and inspected by Safety and Infection Control.

AFTER WORK IS COMPLETED:

8. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction.

9. Remove isolation of HVAC system.

Additional Requirement or Concerns:

SIGNATURES:

DATE:

Sheet1