36C26120B0007-A0002004.pdf

Pre-Construction Risk Assessment (PCRA) VA Northern California Health Care System

Attachment A Policy Statement 138-56 March 1, 2019

Pre-Construction Risk Assessment

Project Name: Planned Project Start Date:

Project Number:

PM / COR P.O.C.: P.O.C. extension:

Location of Construction: Estimated Duration:

Safety/Life Safety Risk Assessment-Safety officer should be involved in the design/planning of all projects

Y N FIRE AND LIFE SAFETY IMPACTS

Will egress routes and exit signage from occupied areas remain unchanged? If No, ILSM is needed.

Will exit stairs remain unobstructed with appropriate fire protection? If No, ILSM is needed.

Will fire & smoke compartments remain intact & unchanged? If No, ILSM is needed.

Will fire alarm and detection systems remain functional & unimpaired; outages <4 hours?

If No, ILSM is needed.

Will fire suppression systems remain functional & unimpaired; outages <10 hours? If No, ILSM is needed.

Will construction area be separated by solid non-combustible smoke tight partitions? If No, ILSM is needed.

Will emergency access by Fire Department remain unobstructed? If No, ILSM is needed.

Will hot work be performed? If Yes, submit hot work permit to Safety

Will the project introduce other significant hazards? If Yes, describe below

Y N CONSTRUCTION ACTIVITY

Will there be any anticipated utility shutdowns? (Communications, electrical, heating/cooling, HVAC, medical gases, vacuum, water, sewer)

If Yes, describe necessary mitigation below

Will there be nuisance noise levels for adjacent areas? If Yes, describe necessary mitigation below Will vibration levels be affect operations of sensitive medical equipment? If Yes, describe necessary mitigation below

Y N PHYSICAL SECURITY IMPACTS

Will the construction compromise security? If Yes, describe necessary mitigation below

Y N CONTRACT COMPLIANCE

Will contract clauses be included for enforcement of identified risks? If Yes, describe necessary mitigation below

Y N ENVIRONMENTAL

Will the project require a NEPA assessment? Contact GEMS for a determination. If Yes, submit draft NEPA to GEMS

Will the project require a permit from the Air Quality District? Contact GEMS for a determination. If Yes, submit draft to GEMS

Will this project require a storm water permit? Contact GEMS for a determination. If Yes, submit draft to GEMS

Y N HAZARDOUS MATERIALS

Will this contract disturb known asbestos containing material (ACM)? Contact Safety for a determination. If Yes, describe necessary intervention:

Will this contract complete work with a biological area such as a lab? If Yes, Facility Specific Training required.

Will contract require the use of hazardous chemicals? If Yes, review by facility IH is required

Y N INFECTION CONTROL

Will this contract require an Infection Control Risk Assessment? If Yes, ICRA shall be completed prior to construction start.

Additional Requirements and Description of Mitigation:

Construction Safety Specialist / Safety Specialist Signature: Date:

Infection Control Representative Signature: Date:

VA Police Signature: Date:

Project Section Manager Signature: Date: