36C26119R0026-008.pdf

MCM 111W-07 Attachment C MCMMCM

Post at Construction Site Rev. May 2014

VA Medical Center, San Francisco Infection Control Construction Permit

Project Name: Location of Construction:

Project Number: Contractor:

Project Engineer: Construction Start Date:

Phone No: Plan Construction Completion Date:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK

GROUP

TYPE A: Inspection, non-invasive activity

GROUP 1: Low Risk

TYPE B: Small scale; short duration; moderate to high levels

GROUP 2: Medium Risk

TYPE C: Activity generates moderate to high levels of dust; requires >1 work shift

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities requiring consecutive work shifts

GROUP 4: Highest Risk

PRECAUTIONS DURING CONSTRUCTION ACTIONS AFTER COMPLETION OF PROJECT

Class I

Date:

Initials:

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

2. Immediately replace a ceiling tile displaced for visual inspection upon completion of inspection.

Area is left exactly as it was prior to the start of project

Class II

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

2. Water mist work surfaces to control dust while cutting sheetrock, wood, tile or metal.

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area.

6. Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with disinfectant.

2. Contain construction waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Remove isolation of HVAC system in areas where work is being performed.

5. Ensure that the air ventilation (intake/output is working properly).

Class III

In addition to Class II Precautions:

1. Obtain Infection Control Permit before construction begins.

2. Remove or Isolate HVAC system in area where work is being done to prevent contamination of the duct system.

3. Complete all critical barriers or implement control cube method before construction begins.

4. Maintain negative pressure within work site utilizing HEPA equipped air filtration units.

5. Contain construction waste before transport in tightly covered containers.

6. Cover transport receptacles or carts. Tape covering unless solid lid.

In addition to Class II Actions:

1. Do not remove barriers from work area until completed project is inspected by the VAMC Safety Officer and Engineering Service.

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

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area to remove any dust film.

5. Remove isolation of HVAC system in areas where work is being performed.

6. Ensure that the air ventilation (intake/ output is working properly).

Class IV

In addition to Class III Precautions:

1. Obtain Infection Control Permit before construction begins.

2. Seal holes, pipes, conduits, and punctures properly.

3. Construct ante-room and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or have personnel wear cloth or paper coveralls that are removed each time they leave work site.

In addition to Class III Actions:

1. Do not remove barriers from work area until completed project is inspected by the VAMC Safety Officer and Engineering Service.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Cover transport receptacles or carts. Tape covering unless solid lid.

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

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with disinfectant.

7. Remove isolation of HVAC system in areas where work is being performed.

Additional Requirements:

Exceptions/additions to this permit are noted by attached memorandum

Permit Requested By: Permit Authorized by:

Date: Date: