9) Interim Life Safety Measures (ILSM).pdf

EDWARD HINES JR. VA HOSPITAL

FACILITIES MANAGEMENT SERVICE

INTERIM LIFE SAFETY MEASURES

OCCUPANT IMPACT EVALUATION WORKSHEET

DESCRIPTION OF LSC DEFICIENCY OR CONSTRUCTION PROJECT:

578-21-703

SIGNAGE

1. Will the above described LSC deficiency or construction project hinder the occupants in the immediate area from effectively implementing RESCUE?

NO

If YES is checked above, will the condition described exist for more than one working day?

N/A

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the compromise of safety and directing a higher level of awareness of fire hazards.

SIGNS POSTED BY: DATE:

2. Will the above described LSC deficiency or construction project hinder the occupants in the immediate area from effectively activating a pull station fire ALARM?

NO

If YES is checked above after question 2, will the condition described exist for more than one working day?

N/A

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants that the fire alarm pull station is out of service and instructing the occupants to call the Hines Police Department by telephone at extension 22323 to report a fire.

SIGNS POSTED BY: DATE:

3. Will the above described LSC deficiency or construction project hinder the ability of the occupants in the immediate area to CONFINE a fire?

NO

If YES is checked above, will the condition described exist for more than one working day?

N/A

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the condition and listing alternative actions to be taken until the condition is remediated.

SIGNS POSTED BY: DATE:

4. Will the above described LSC deficiency or construction project reduce or hinder the ability of the occupants in the immediate area or the community Fire Department to EXTINGUISH a fire?

NO

If YES is checked above, will the condition described exist for more than one working day?

N/A

If the condition will exist for more than one working day, signage must be prepared and posted informing the occupants of the condition and listing alternative actions to be taken until the condition is remediated. Additionally, the community Fire Department will develop a contingency firefighting tactical plan for the area. In the case of construction projects, that contingency plan must be approved and in place prior to permitting any work to start at the job site.

SIGNS POSTED BY: DATE:

5. Will the above described LSC deficiency or construction project hinder the occupants' ability to EVACUATE the building or area?

NO

If YES is checked above, will the condition described exist for more than one working day?

N/A

If the condition will exist for more than one working day, signage must be prepared and posted advising the occupants of the condition and describing alternate routes of egress.

SIGNS POSTED BY: DATE:

TRAINING

6. Does the ILSM signage pertaining to RESCUE provide sufficient information and instruction in itself to ensure proper occupant response during an emergency incident?

N/A

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

TRAINING CONDUCTED BY: DATE:

7. Does the ILSM signage pertaining to ALARM provide sufficient information and instruction in itself to ensure proper occupant response during an emergency incident?

N/A

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

TRAINING CONDUCTED BY: DATE:

8. Does the ILSM signage pertaining to CONFINE provide sufficient information and instruction in itself to ensure proper occupant response during an emergency situation?

N/A

If the signage is determined to be inadequate to ensure proper occupant response, Safety will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

TRAINING CONDUCTED BY: DATE:

9. Does the ILSM signage pertaining to EVACUATE provide sufficient information and instruction in itself to ensure proper occupant response during an emergency situation?

N/A

SI NATURE OF SAFETY STAFF

If the signage is determined to be inadequate to ensure proper occupant response, Project/Planning will provide the personnel affected with additional instruction and training as necessary. Such training will be documented.

TRAINING CONDUCTED BY: DATE:

FIRE DRILLS

10. Will the above described LSC deficiency or construction project necessitate altering staff response to RESCUE, ALARM, CONFINEMENT, EXTINGUISHMENT and/or

EVACUATION?

N/A

If YES is checked above, will condition exist for more than sixty days?

N/A

If staff response to Rescue, Alarm, Confinement, Extinguishment and/or Evacuation will be altered for more than sixty days, the Safety Section will increase the frequency of scheduled fire drills in the area affected to two per shift per quarter.

ADDITIONAL FIRE DRILLS SCHEDULED BY: DATE:

INSPECTION

If evaluation indicates that one or more ILSMs must be used for this deficiency or project, daily inspection of the site by Safety and Police personnel will be required. Each inspection must be documented on the ILSM High Hazard Inspection Report.

INSPECTION REQUIRED: NO

INSPECTION SCHEDULED BY: DATE:

17 . C 9

DATE