S06_PCRA Form .pdf

Pre-Construction Risk Assessment (PCRA) Permit

This page must be posted at the entrance to the project area for Small scale and large scale activities. Print on legal 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/review date:

Describe activities to be performed and time frame: Replace remaining roof above warehouse that was not done with the construction of Bldg 2 in 2015.

Activity Type

Pre Construc-tion

Post award

Control measures to be in place for the duration of the activity (Check the box in column 1 for the Activity Type to indicate the Control Measures)

(Check all that apply in column 2, Preconstruction, during design phase) (Check all that apply in column 3, Post Award, during first contractor meeting)

Minor in-house projects

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

☒ ☐ 2 Site visits of construction area are required weekly by member of multi-disciplinary team. Site visits will be documented on standard checklist. (N/A for short term projects)

☒ ☐ 3 Site specific safety plan, task hazard analysis, and hazard communication required to be provided by the contractor or maintenance and approved. (Use activities field above)

☒ ☐ 4 Must address identified hazards and controls that will be implemented to ensure minimal impact patients, employees, contractors, and facility. (see back page)

☒ ☐ 5 Communication and coordination plan for all affected areas should be developed.

All control measures in the row above and the following:

Small-scale

1 Hazard communication chemical inventory required to be provided by the contractor and approved.

☒ ☐ 2 ILSMs in place and staff trained on situation (See MCP 221) Attach ILSM which will serve as the Life Safety Risk Assessment. Safety - Home (sharepoint.com)

☒ ☐ 3 Hot Work or burn permits in place and staff trained (see MCP 242) MCM242 ATTACHMENT A - Hot Work Permit.docx

☒ ☐ 4 LOTO procedures in place and staff trained on their use (see MCP 223) LOTO Procedure and Notification Guidance - MCP 233 Attachment A.docx

☒ ☐ 5 Site visits will be reviewed using the criteria in standardized guide. Weekly Construction Safety Rounds

Form.docx

☒ ☐ 6 Daily inspections of the site are to be conducted by the General Contractor and documented on their daily log.

☒ ☐ 7 Check for additional hazards by using the checklist on page 2.

All control measures in both rows above and the following Activity Hazard

Analyses and Control Plans as applicable

(check all that apply):

Large-scale

☐ ☐ 1 Excavation safety plan is required (pre-construction column). Plan in place (post-award column)

☐ ☐ 2 Dust control plan is required (pre-construction column). Plan in place (post-award column)

☐ ☐ 3 Pollution prevention plan is required (pre-construction column). Plan in place (post-award column) (Contact GEMS Manager)

☐ ☐ 4 Dig safe paperwork is required (pre-construction column). Paperwork is filed (post-award column)

☐ ☐ 5 Crane lift plan is required (pre-construction column). Plan in place (post-award column) It must describe the following: Crane placement, crane swing and crane load evaluation.

☐ ☐ 6 Fall protection plan is required (pre-construction column). Plan in place and staff trained (post-award column)

7 Confined entry plan is required (pre-construction column). Plan in place and staff trained (post-award column) (see MCP 243) Confined Space

*The location of all Activity Hazard Analyses and Control Plans (excavation, dust, pollution, etc.) as applicable shall be identified on this permit and shall be made available to all workers on the job.

Explain any omissions to control measures listed above:

N/A

Additional requirements:

N/A

☒ Yes ☐ No Infection Control Risk Assessment (ICRA) is required for the Activity?

Pre-Construction (design phase) Post-Award

Infection Prevention signature

Project Manager (COR) signature

Safety Officer and Chair, Construction Safety Committee signature https://dvagov.sharepoint.com/sites/vhaiowhubsafetymain https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/MCM242%20ATTACHMENT%20A%20-%20Hot%20Work%20Permit.docx?d=w32dafce942894b2ca5b1ef89489fa7fc&csf=1&web=1&e=WHZInx https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/MCM242%20ATTACHMENT%20A%20-%20Hot%20Work%20Permit.docx?d=w32dafce942894b2ca5b1ef89489fa7fc&csf=1&web=1&e=WHZInx https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/LOTO%20Procedure%20and%20Notification%20Guidance%20-%20MCP%20233%20Attachment%20A.docx?d=wf59767a4a0b547e6822527a5e02909cc&csf=1&web=1&e=TuWfy8 https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/LOTO%20Procedure%20and%20Notification%20Guidance%20-%20MCP%20233%20Attachment%20A.docx?d=wf59767a4a0b547e6822527a5e02909cc&csf=1&web=1&e=TuWfy8 https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/Weekly%20Construction%20Safety%20Rounds%20Form.docx?d=we58e44577ab347a581612654008b518f&csf=1&web=1&e=O3wDva https://dvagov.sharepoint.com/:w:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Construction%20Forms%20and%20Permits/Weekly%20Construction%20Safety%20Rounds%20Form.docx?d=we58e44577ab347a581612654008b518f&csf=1&web=1&e=O3wDva https://dvagov.sharepoint.com/:f:/r/sites/vhaiowhubsafetymain/Shared%20Documents/Confined%20Space?csf=1&web=1&e=PPdrFU

Pre-Construction Risk Assessment (PCRA) Permit

Pre-Construction Contact List (during design phase)

Area Service(s)/Type(s) of Area(s) (e.g., OR, Unit/Ward)

Point of Contact (POC) POC Phone # Date Construction plan communicated to POC?

Activity Area**

N/A N/A N/A N/A

Area Above

Area Below

Warehouse Engineering

Aaron Nissley Jessica Beswick

(319) 338-0581 x636445

(319) 383-2693

05/01/26 05/01/26

Adjacent Area 1

Adjacent Area 2

Adjacent Area 3

Adjacent Area 4

* There may be more than one Service/type of area for each row. List all. The information entered on this table must be used in the ICRA if required.

** List the area(s) in which the construction/renovation/maintenance activity will occur.

Post-Award Contact List Area Service(s)/Type(s) of Area(s)

(e.g., OR, Unit/Ward) Point of Contact (POC) POC Phone # Date Construction plan communicated to POC?

Activity Area**

Area Above

Area Below

Adjacent Area 1

Adjacent Area 2

Adjacent Area 3

Adjacent Area 4

* There may be more than one Service/type of area for each row. List all. The information entered on this table must be used in the ICRA if required.

** List the area(s) in which the construction/renovation/maintenance activity will occur.

Note: PCRA Risk Assessment guide and this form can be found on the Safety SharePoint site under the Construction Forms and Permits folder Safety - Home (sharepoint.com) https://dvagov.sharepoint.com/sites/vhaiowhubsafetymain