S06_ICRA Permit.pdf

(ICRA) Infection Prevention and Control Construction/Renovation/Maintenance Permit

VHA-ICRA-2023-1.0 and ICVAHCS 2023-3.0

This page must be posted at the entrance to the project area for Level III and Level IV activities. Print on legal or 11 by 17 paper

Unique permit number or project name and number: Replace Warehouse Roof; 636A8-26-003

Location of construction/renovation/maintenance: Iowa City VA Medical Center; Building 2 Roof

VA Project Manager/COR name: Sean Farmer Project start date: 05/01/2026

Contact phone number: 319-321-5956 Est. Completion date: 10/01/2026

Primary Contractor or Lead Shop: TBD Permit expire or review date:

Fill in from ICRA Decision Matrix which can be found on the ICRA Risk Assessment Guide found in the Safety SharePoint, Construction Forms and Permits. Safety - Home (sharepoint.com)

Table 1: Activity Category (A, B, C, or D)

C Table 3: Overall Patient Risk Category (Low, Medium, High, or Highest)

LOW

Table 4: Level of Infection Prevention and Control Precautions (I, II, III, or IV) II

Level of Precautions

(Table 4)

Pre Construc-tion

Post Award

Control measures to be in place for the duration of the activity (Check the box for the activity’s Level of Precautions to indicate the Control Measures)

Level I (Maintenance)

☒ ☒ 1. Perform work activity in a manner that does not create dust.

☒ ☒ 2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

☒ ☒ 3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

All control measures in Level I and the following:

Level II (Maintenance)

☐ ☐ 1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

☒ ☒ 2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

☒ ☒ 3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

☐ ☐ 4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system

☒ ☒ 5. Seal doors, to prevent dust migration

☒ ☒ 6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

☒ ☒ 7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

☐ ☐ 8. Nonporous/smooth and cleanable containers (covered) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

☒ ☒ 9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy.

Sticky mats must be changed routinely and when visibly soiled.

☒ ☒ 10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

All control measures in Levels I and

II and the following:

Level III (Construction)

☐ ☐ 1. Ensure availability of equipment for cleaning hands. (Towlettes)

☐ ☐ 2. Construct and complete critical barriers meeting NFPA 241 requirements. Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

☐ ☐ 3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

☐ ☐ 4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop if applicable for barrier type).

☐ ☐ 5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed outdoors (unless a work specific waiver is approved by VHA’s Office of Healthcare Engineering); this must be maintained continuously 24/7 for the duration of the project. Exhaust discharged directly to the outdoors that is 25 feet or greater from entrances, air intakes and windows is not required to be HEPA-filtered. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

☐ ☐ 6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment to continually monitor and document negative pressurization. The “ball in the wall” or similar apparatus are not acceptable.

All control measures in Levels I, II and III and the following:

Level IV (Construction)

☐ ☐ 1. Barriers must be hard barriers unless temporary to install final barrier.

☐ ☐ 2. Containment must include an anteroom to ensure pressure control, Anteroom must be large enough for equipment staging, cart cleaning, workers’ PPE and cleaning.

☐ ☐ 3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

☐ ☐ 4. Workers must wear shoe covers or have a method to clean shoes in anteroom Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area).

Damaged shoe covers must be changed immediately.

Explain any omissions to control measures listed above:

Level II Omissions

1. Work will be performed outside

4. Potable water systems will not be affected by this work

8. Work will be performed outside

Additional requirements:

1. The contractor will install and maintain mesh filters to prevent particulate created during construction, from entering the medical center’s HVAC system.

Pre-Construction Post-Award

Project Manager (COR) signature

Infection Preventionist signature https://dvagov.sharepoint.com/sites/vhaiowhubsafetymain