Attachment 1_Enclosure A - WorkPermitForms3.0.pdf

WORK AUTHORIZATION REQUEST 3.0

Work Permit #: Additional Tracking #:

(i.e. Contract, SO, DMLSS, Project):

Project Name: Phase(s):

Location/Building: Floor: Room(s):

Start Date: End Date: Work Hours:

Project Description (brief):

NMCSD Project Mgr: Phone:

General Contractor/CM/Prime:

Superintendent/Foreman (Day): Phone:

(7:00am-4:00pm daily)

Superintendent/Foreman (Evening): Phone:

(after 4:00pm)

Documents required for Work Authorization Approval:

☒ Infection Control Risk Assessment (ICRA) – (pages 2-3)

☒ Patient Impact Risk Assessment (PIRA) – (page 4)

☒ Fire Protection & Life Safety Assessment – (pages 6-9)

☒ Environmental Risk Assessment – (pages 10-11)

☒ Contractor Action Plan & Requirements - (pages 12-13)

☒ Detailed Scope of Work ☒ Floor Plans – IC plans, Phasing Plan, Debris Path, Abatement Plan, etc.

☒ Work Schedule ☒ Equipment/Material Specification Sheets

Additional documents required based on the Scope of Work: (note: some documents will be required to be submitted prior to work approval and/or submitted/maintained during the life of the project)

☐ Utility Outage Request – (pages 14-15)

☐ Penetration Permit – (page 16)

☐ Access to Fire Alarm Master Panel – (page 17)

☐ Fire Watch Inspection Worksheet – (pages 18-22)

☐ Hourly ☐ 30-minutes ☐ 15-minute ☐ Infection Control Construction Permit (ICCP) – (page 23)

☐ Hot Work Authorization Permit/PAI Hot Work Record – (page 24)

☐ Real Property Inventory (RPIE) Data Collection Sheet – (page 25)

☐ Bio-Medical Equipment Inventory List – (page 26)

☐ Others:

FMD Project Manager (documents submitted meets the requirements for work authorization):

Sign/Date:

Contractor (I agree to implement all the requirements noted above):

Sign/Date:

WPP 3.0 (4/2022)

INFECTION CONTROL RISK ASSESSMENT (ICRA) CLASS DETERMINATION

STEP 1: Construction Type will be determined using the following guidelines:

TYPE A

Inspection and Non-Invasive Activities (includes, but not limited to):

• Removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet

• Painting (but not sanding)

• Wall covering or electrical trim work

• Minor plumbing

• Activities which do not generate dust or require cutting walls or access to ceilings other than for visual inspection.

TYPE B

Small scale, short duration activities creating minimal dust (includes, but not limited to):

• Installation of telephone and computer cables

• Access to chase spaces

• Cutting walls or ceilings where dust migration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components (includes, but not limited to):

• Sanding of walls for painting or wall covering

• Removal of floor coverings

• Ceiling tiles and casework

• New wall construction

• Minor duct work or electrical work above ceilings

• Major cabling activities

• Any activity which cannot be completed within a single work shift

TYPE D

Major demolition and construction projects (includes, but not limited to):

• Activities which requires consecutive work shifts

• Requires heavy demolition or removal of a complete cable system

• New construction

STEP 2. The Infection Control Patient Risk Group will be determined based on the location where the work will take place:

LOW RISK MEDIUM RISK HIGH RISK HIGHEST RISK

• Offices

• Support areas

• Lobbies

• Corridors between

Units/Buildings

• Warehouse

• Cardiology

• Echocardiography

• Endoscopy

• Nuclear Medicine

• PT/OT

• Radiology/MRI

• Respiratory Therapy

• Medical Offices

• Outpatient Clinics (except

Oncology, Transplant and

JMFC)

• Psychiatric Units

• Elevator Areas

• Hospital P-Waves and

Corridors

• ER

• Labor & Delivery (except for

C-sections rooms)

• Laboratories (specimens)

• Nurseries

• Outpatient Surgery

• Pediatrics

• Pharmacy (except IV mix/prep area)

• PACU

• Surgical Units

• Medical Units

• Hemodialysis

• Rehabilitation Units

• Food Service Areas

• Areas with Immuno-compromised Patients-transplant units

• Cardiac Cath Lab

• Central Sterile Processing

• Intensive Care Units (ICUs)

• Oncology/Radiation

Oncology

• Operating Rooms (including

C-Sections rooms)

• Outpatient Clinic (Oncology, transplant, JMFC)

• Pharmacy with IV mix/prep

• Negative Pressure Isolation

Rooms

** B9 – Vivarium is included in the above risk groups based on location within the building **

☐ FORM IS REQUIRED IF BOX IS “CHECKED”

WORK PERMIT #:

INFECTION CONTROL RISK ASSESSMENT (ICRA) CLASS DETERMINATION (cont)

STEP 3. Using the following Infection Control Matrix, the risk classification will be determined by Construction Type and Patient Risk Group:

“Construction Type” + “Patient Risk Group” = Containment Class

Patient Risk Group Construction Project Type Type A Type B Type C Type D

LOW I II II III/IV*

MEDIUM I II III IV

HIGH I II III/IV* IV

HIGHEST II III/IV* III/IV* IV

* Signifies it is the discretion of the Infection Prevention Officer to decide whether the project is to be classified a Class III or Class IV containment.

Containment Class Selected:

Containment Class Required by IC:

STEP 4. Completion of the WPA with the final Infection Control recommendations. Note: A signed Infection Control Construction Permit (ICCP) is required for ALL Class III and/or Class IV containment before ANY work begins.

References:

Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (RR10): 1-31.

The American Institute of Architects Academy of Architecture for Health. (2003) Guidelines for Design and Construction of Hospital and Health Care Facilities. AIA. Washington, DC.

The Association for Professional in Infection Control (APIC), Grid Tool, 2005.

PATIENT IMPACT RISK ASSESSMENT

Location of Construction: Start Date:

Project Coordinator: End Date:

Contractor Performing Work:

Construction Site Supervisor/Phone #:

Area/Nurse Manger/Phone #:

DEPT LOCATION: IMPACT: DEPT LOCATION: IMPACT

Above Site: ☐ HI ☐ MED ☐ LOW Below Site: ☐ HI ☐ MED ☐ LOW

Front of Site: ☐ HI ☐ MED ☐ LOW Behind of Site: ☐ HI ☐ MED ☐ LOW

Right of Site: ☐ HI ☐ MED ☐ LOW Left of Site: ☐ HI ☐ MED ☐ LOW

RISK TOPIC ISSUE ADMINISTRATIVE ACTIONS

UTILITIES

IMPACT

☐ One or more utility systems will be shut down or impaired.

☐ No Utility Impacts

☐ Only Engineering staff may shut down systems ☐ Five (5) day notice to Engineering and affected department(s) prior to shutdown ☐ 24 Hr notice to Engineering and affected department(s) prior to shutdown ☐ 15 min notice to Engineering and affected department(s) prior to shutdown ☐ Signed shutdown permit must be issued and posted ☐ An Engineering/Facilities office telephone line is available to affected departments and will be promoted to all affected departments 24 hours/15min in advance, and by postings.

PATIENT CARE

ACTIVITIES

☐ Patient Care Activities will be compromised or impaired.

☐ No Patient Care Activities to be Impacted

☐ Communication to the affected staff on daily basis, as applicable.

☐ In case of issues affecting patient care delivery, the on-call Nursing

Supervisor’s Office line is set up for all affected departments.

☐ The construction site manager responds and to project-related patient care concerns.

☐ If regular patient transport routes are disrupted - affected units need to be notified at least one week in advance and detours need to be clearly marked.

NOISE &

VIBRATION

☐ Construction activities will create elevated noise Class that may affect adjacent areas to the project.

☐ N/A - No noise impacts expected.

☐ Activities which may increase the normal vibration level will be conducted during the project (including jackhammering, cement cutting, sawing, heavy equipment use, coring, pumping, high velocity fan use, excavation, blasting, demolition, powered actuated gun use).

☐ N/A - No Vibration impacts expected

☐ Work will be scheduled to minimize noise/vibration impacts.

☐ 24-hour notice prior to noise or vibration production phase ☐ 15-minute notice prior noise or vibration production phase (critical care areas) ☐ Noise/Vibration levels impact assessments to be conducted during the active phases of the project.

☐ An Engineering/Facilities office telephone line is available to affected departments and will be promoted to all affected departments 24 hours in advance, 15 minutes in advance, and by postings.

SECURITY

CONCERNS

☐ Access to construction via common areas to patient, staff or visitor

☐ Unit fully restricted (closed off)/No access to construction site by non-authorized personnel.

☐ Restricted access/barriers to construction site ☐ All contractor’s staff to wear ID while on site.

☐ COMMENTS:

Additional Requirements (if scope of project changes Patient Safety needs to be notified):

Exception/Additions to this permit are noted by attached memoranda: Date: Initials:

Permit Requested By:

Permit Authorized By:

☐ FORM IS REQUIRED IF BOX IS “CHECKED”

☐ FORM IS REQUIRED IF BOX IS “CHECKED”

FIRE PROTECTION & LIFE SAFETY ASSESSMENT

Work Permit #: LS Work Order #:

Contractor: Project Manager:

Project Type: ☐-Maintenance ☐-IMD ☐-Service Provider ☐-Contractor ☐-Other:

Project Name: Base/Building #:

ALL questions MUST be answered by either the Project Manager, Supervisor, or Contractor in order to obtain project approval. If answering “YES” to any question, then provide specific details on: Location, Scope of Work, Equipment Details, Timing of Work, and Duration of Work. Otherwise indicate “N/A”. If unable to answer a question(s) or assistance is needed, then contact the Facilities Management Department (FMD) Fire Projection Engineer (FPE).

Based upon the completion of this form, an Interim Life Safety Measure (ILSM) may be required. The FMD-FPE shall review this form and subsequently, complete the ILSM forms and provide notification to the Project Manager, Supervisor, or Contractor of any actions required for inspections, alternate egress signage, hot work permits, etc.

1. Will fire alarm systems (pull stations/detectors/panels/tamper switches/horn or strobe notification appliances) be added, removed, replaced, or modified? ☐ YES ☐ N/A

2. Will fire suppression systems (wet-pipe/dry-pipe/pre-action/clean agent/kitchen hood) be added, removed, replaced or modified? ☐ YES ☐ N/A

3. Will corridors, hallways, aisles, stairways, doors, ramps, or other egress paths be impaired or blocked? If so, then provide the alternate egress pathways. ☐ YES ☐ N/A

FIRE PROTECTION & LIFE SAFETY ASSESSMENT (con’t)

Work Permit #: LS Work Order #:

4. Will fire/smoke barrier penetrations be added, removed, replaced or modified? If so, then provide the Listed or Approved firestop assembly (Hilti system preferred) and the qualification of the installer. ☐ YES ☐ N/A

5. Does the project add, remove, or replace fire/smoke doors and/or windows? If so, then provide the fire rating and construction details for the new/modified door/window. ☐ YES ☐ N/A

6. Will building exit components (stairs/doors/ramps) be added, removed, replaced or modified? ☐ YES ☐ N/A

7. Will suspended ceilings or ceiling tiles be affected? ☐ YES ☐ N/A

8. Will combustible material be added or removed (cardboard boxes/storage bins/computers/electronics equipment/paper/flammable and combustible liquids and gases/furniture)? Will there be pallet storage (plastic/wood/metal)?

Approximate storage height? Indicate if the materials are to be removed every shift, left for the duration of the project, or permanently installed. ☐ YES ☐ N/A

9. Will ignition sources be added or removed (heaters/power banks/powered electronics equipment)? Indicate if the ignition sources are to be removed every shift, left for the duration of the project, or permanently installed. ☐ YES ☐ N/A

10. Will hot work (welding/cutting/grinding/heat treatment) be performed? If so, then also complete the Hot Work Permit.

☐ YES ☐ N/A

11. Will wall, ceiling, or floor finishes (paint/wallpaper/curtains/carpets/foam matting) be installed? Will existing walls, ceilings, or floors be removed or altered? If so, then provide the fire test ratings for the finish material assembly.

☐ YES ☐ N/A

12. Will emergency lighting or emergency exit lights be added, removed, replaced, or modified? ☐ YES ☐ N/A

13. Will portable fire extinguishers be added, removed, or replaced, excluding temporary fire extinguishers required for construction support or hot work? ☐ YES ☐ N/A

14. Will electrical cable (power/control/communications) be installed? If so, then provide the fire rating for the cable.

☐ YES ☐ N/A

15. Will there be any excavation work? ☐ YES ☐ N/A

16. Will the Fire Department access roads or pathways be impacted? ☐ YES ☐ N/A

17. Will backflow preventers, fire pumps, post indicator valves, fire hydrants, or fire department connections be added, removed, replaced, or modified? ☐ YES ☐ N/A

FMD-FPE Section ONLY:

☐ ILSM are Required ☐ ILSM not Required Comments:

Signature:

ENVIRONMENTAL RISK ASSESSMENT

The environmental policy for NMCSD requires military, civilian, and contract personnel to conduct business in a socially responsible and ethical manner that seek to protect the environment.

NMCSD has an environmental policy which requires all personnel to operate in a manner to minimize waste, prevent spills, and dispose of waste responsibility.

The Command shall reuse, recycle, and procure recycled materials where practical and comply with all applicable Federal, State, local regulations, and Department of Defense directives.

Work Permit #: Location of Construction:

Project Coordinator: Project Start Date:

Estimated Duration: Contractor Performing Work:

Area Mgr Name/Phone#: Construction Site Sprv/Phone#:

RISK TOPIC ISSUE ADMINISTRATIVE ACTION

ENVIRONMENTAL POLICY

☐ Has all construction personnel been briefed on the environmental policy for the Command?

☐ All construction personnel briefed on the Command environmental policy in the brown badge training.

☐ Construction personnel did not partake in brown badge training, but was informed and briefed on the environmental policy for the Command.

LEAD & ASBESTOS ABATEMENT

☐ No lead and or asbestos is present in construction site.

☐ Lead and or asbestos is present but will not be affected during construction.

☐ Lead and or asbestos abatement will be done in construction site.

☐ Lead and or asbestos abatement plan, delivered and accepted by the NMCSD Asbestos Program Manager.

☐ If applicable, Air Pollution Control District (APCD) 10-day notification needs to be submitted to the NMCSD Asbestos Program Manager.

☐ All abatement documentation such as air monitoring results (daily & clearance, as applicable) need to be delivered to NMCSD Asbestos Program Manager, Project Manager and Facilities Manager.

☐ As-built floor plans with room numbers to indicate where the abatement was performed as well as where clearance samples were collected.

☐ All lead and asbestos non-hazardous and hazardous waste requires signed manifest to be submitted to environmental.

HAZARDOUS MATERIALS & WASTE

☐ No hazardous materials to be used. ☐ All hazardous materials or waste Safety Data Sheets (SDS) must be available and reviewed against the prohibited and controlled chemical list. SDS’s must be available onsite.

ENVIRONMENTAL RISK ASSESSMENT (cont)

HAZARDOUS MATERIALS &

WASTE (CONT)

☐ Hazardous materials (liquids or gases) will be used onsite:

☐ Flammables ☐ Corrosive

☐ Toxic ☐ Reactive

☐ Compress Gases (e.g. Welding tanks)

☐ Odorous Products (e.g. tar, mastic, paints, solvents, etc.)

☐ Mercury Lamps

☐ Other:

☐ Hazardous material inventory log has been submitted.

☐ Spill kits will be onsite if hazardous materials are present.

☐ All hazardous material will be removed from the building at the end of day. No storage permitted.

☐ All paint cans will be disposed of as a hazardous waste.

☐ Batteries, lightbulbs, and all mercury containing equipment will be disposed of as universal waste.

☐ All waste will be labeled properly and placed in lockable storage containers/room, and have proper signage.

☐ Other:

SOLID WASTE RECYCLING &

DISPOSAL

☐ Construction activities will have solid waste to be disposed of.

☐ N/A – No Construction activities will result in solid waste.

☐ Solid construction waste will be disposed in proper construction debris dumpster.

☐ All scrap metal will be disposed in the metal recycling bin.

☐ All cardboard and wood will be collected and recycled.

☐ Mercury lamps will be collected and recycled.

SPILL PREVENTION

COUNTERMEASURE PLAN

☐ No hazardous materials to be used.

☐ Hazardous materials to be used in construction site.

☐ Spill response plan available at construction site.

☐ Staff trained on spill kit use.

☐ Spill kit will be onsite if hazardous materials are present.

☐ All drains will be covered during the use of hazardous materials to prevent hazardous materials going down the drain.

Permit Requested by: Date:

Permit Authorized by Environmental: Date:

Exceptions/Additions to this permit are noted by attached memoranda

Date: Initials:

If you have any questions or concerns for any of these environmental risk topics please contact Kris Clemens (619-532-9183) kristian.a.clemens.civ@mail.mil or Mary Esparza (619-532-5947) mary.t.esparza.civ@mail.mil

CONTRACTOR ACTION PLAN & REQUIREMENTS

This plan MUST be included, executed and documented as part of the job-site Health and Safety Plan

1) Description of construction/renovation work site:

Work Permit #:

Project #: Project Name:

Location/Building:

2) Identify the specific routes “in” and “out” of the construction/renovation site:

3) Designated work hours (any work outside these hours MUST have prior approval):

4) Designated hand washing sinks for construction workers:

5) Designated elevators to be used by construction personnel:

6) Designated first aid plan:

CONTRACTOR ACTION PLAN & REQUIREMENTS (cont)

7) Fire plans (include location of pull stations, R.A.C.E, and egress routes):

8) Disaster response plan:

9) Restricted areas:

10) Designated contractor parking area:

11) Command smoking policy:

IP Signature: Date:

IP Comments:

EH&S Signature: Date:

EH&S Comments:

UTILITY OUTAGE REQUEST

Job Title: Work Permit #: Contractor Outage #:

Type of Outage:

☐HVAC ☐Plumbing ☐Electrical ☐Med Gas ☐Fire Sprinkler ☐Other:

Date Outage Request Submitted:

Contractor:

Job Site Supervisor Phone #:

CM/ET Representative: Phone #:

What Building(s), Level(s), Block(s), Department(s) and Room(s) *if less than 15 rooms* are affected by this outage:

What is the purpose of this outage? Provide a description of each activity to be performed start to finish (including times) for each (MOP). Include project’s IFC construction drawings

Optimal Date/Time:

system is requested to be secured:

Alternative Date/Time:

system is required to be secured (minimum 7 days forward):

Will JJWWS or COGEN support be required? ☐ Yes ☐ No (Explain How)

MANDATORY CHECKLIST

1) Did you provide a Job Title?............................................................................................................................... ☐ Yes ☐ No

2) Did you request an Optimal Date/Time?............................................................................................................ ☐ Yes ☐ No

3) Did you request an Alternate Date/Time?.......................................................................................................... ☐ Yes ☐ No

4) Did you provide a detailed MOP explaining each activity w/timeframe?............................................................ ☐ Yes ☐ No

5) Did you attach floorplan highlighting all impacted devices, registers, fixtures, units & equipment?................... ☐ Yes ☐ No

6) Did you attach plans highlighting the impacted utility from its source to the end users location?...................... ☐ Yes ☐ No

7) Did you add the department names adjacent to the impacted locations on the attached floorplans?............... ☐ Yes ☐ No

8) Did you indicate the containment on the drawings with a “RED” box and word “containment” adjacent to it? ☐ Yes ☐ No

9) Are the materials & parts to perform this outage on site? (if no, place date expected)….☐ Yes ☐ No

UTILITY OUTAGE REQUEST – Impact Statement (to be provided to the end users)

Provide answers/statement to the following:

What utilities are impacted?

How does this utility impact the end users?

Bldg(s) #: Floor(s): Block(s):

What is the mitigation to reduce impact?

PENETRATION PERMIT

(for all FIRE/SMOKE BARRIERS including FLOORS)

Contractor: In-House Work #: Work Permit #:

Date Issued: Expiration Date:

Bldg #: Floor: Unit:

Briefly describe Scope of Work and provide a time table (location and type of penetration)

Manufacturer and Fire Stop material used on this project:

Documentation submitted with permit (select all that apply):

☐ Marked Life Safety Floor Plans ☐ Fire Stop/Fire Stop System Certificates for all qualified installers ☐ Product Specifications

☐ Other:

*** THIS PERMIT MUST BE POSTED ON THE LADDER OR IN THE IMMEDIATE AREA OF WORK *** I acknowledge that Facilities QA must inspect the penetration before work completion and coverage; Failure to do say may result in re-work at no cost to the government.

Contractor: Signature: Date:

TO BE COMPLETED BY FACILITY ENGINEERING, NMCSD

☐ APPROVED ☐ DENIED

Facility Engineering Representative: Date:

Comments:

TO BE COMPLETED BY QUALITY ASSURANCE STAFF

Final Documents Received:

☐ Penetration permit ☐ Photos of repairs with labels in view ☐ Marked floor plans where repairs were made.

☐ PERMIT COMPLETED

I have verified that all penetrations listed above have been repaired as documented per this permit QA Representative: Date:

* MUST NOTIFY THE QUARTERDECK OF ALL FIRE ALARM RELATED ACTIVITY *

FIRE ALARM MASTER PANEL – REQUEST FOR ACCESS

Naval Medical Center, San Diego – 34800 Bob Wilson Drive San Diego 92134 - (619) 532-6400

Work Permit #: Contract/Project #:

Project Name:

Building #: Work Location:

Detailed Work Description:

Reason for Panel Access:

Anticipated hours: Start: Stop:

Panel Location:

CONTRACTOR – Work to be performed by (company):

POC: Phone:

MAINTENACE DEPARTMENT – Under the direction of:

POC: Phone:

Prior to start of work:

- CALL regional dispatch, place fire alarm system in test.

- NOTIFY Quarterdeck

- DISABLE necessary alarms, points, devices

At completion of work the following will be required (if applicable):

- RE-ENABLE fire alarm panel, verify system normal.

- LIST of all points added/deleted – including point address and function.

- COPY of revised/updated points list generated from ONYX System

Request Start Date:

Approved by: Date:

FIRE WATCH INSPECTION FORM – HOURLY

Work Permit #: Fire Department Notification Start Date: Time: Fax #:

Fed Fire POC:

Notified By: Area Covered by Fire Watch:

PRINT NAME OF INSPECTOR (in box next to the time)

TIME / DATE __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__ __/__/__

Notification for fire or other emergencies: cell phone - dial 911: land line - 9-911 and pull fire alarm Any of the following conditions below MUST be reported immediately and corrected

- There is fire, smoke, or a strong smell of smoke, or other evidence of a fire or incipient fire PULL ALARM.

- Fire alarm pull stations, smoke or heat detectors are blocked, obstructed, or rendered inaccessible.

- Fire alarm pull stations, smoke or heat detectors, bells or other fire alarm elements are damaged or broken.

- Fire extinguishers are damaged, do not have the proper inspection tag, blocked, or obstructed, or rendered unavailable to immediate use.

- Exit path is blocked, or obstructed. Exit stairs have any materials or supplies, or debris in stairwell.

- Exit door at bottom of stair is obstructed, or nonfunctional, unable to be easily opened.

- Exit stairs lighting is not operational, areas of the stair are dark or not visible.

- Corridors have trash, debris, or other materials obstructing any part of corridor. Supplies, equipment, materials, and/or waste materials are in corridors.

- Fire and smoke doors are damaged, broken, or unable to close fully, and latch appropriately. Closers do not function fully to close doors.

- Fire and smoke doors are blocked, or obstructed by materials, equipment or wedging

- Trash, debris or other combustible materials stored in rooms or areas adjacent to the corridor.

- Construction materials or equipment storage obstruct the corridor, exit path, stairs, or other use areas.

- Fire separations have holes or penetrations, or unprotected openings.

- There are holes in walls, floors, or fire separations, or other visible changes in the building fire construction that could cause injury or risk to patients or staff.

- Exit lights or illumination of the corridor is burned out, or not operating properly.

FIRE WATCH INSPECTION FORM – EVERY 30 MINUTES

Work Permit #: Fire Department Notification Start Date: Time: Fax #:

Fed Fire POC:

Notified By: Area Covered by Fire Watch:

PRINT NAME OF INSPECTOR (in box next to the time)

Date/Time Day ( ) / / Date/Time Day ( ) / / 1230 1230

0030 1300 0030 1300 0100 1330 0100 1330 0130 1400 0130 1400 0200 1430 0200 1430 0230 1500 0230 1500 0300 1530 0300 1530 0330 1600 0330 1600 0400 1630 0400 1630 0430 1700 0430 1700 0500 1730 0500 1730 0530 1800 0530 1800 0600 1830 0600 1830 0630 1900 0630 1900 0700 1930 0700 1930 0730 2000 0730 2000 0800 2030 0800 2030 0830 2100 0830 2100 0900 2130 0900 2130 0930 2200 0930 2200 1000 2230 1000 2230 1030 2300 1030 2300 1100 2330 1100 2330 1130 2400 1130 2400 1200 1200

Notification for fire or other emergencies: cell phone - dial 911: land line - 9-911 and pull fire alarm

Any of the following conditions below MUST be reported immediately and corrected

- There is fire, smoke, or a strong smell of smoke, or other evidence of a fire or incipient fire PULL ALARM.

- Fire alarm pull stations, smoke or heat detectors are blocked, obstructed, or rendered inaccessible.

- Fire alarm pull stations, smoke or heat detectors, bells or other fire alarm elements are damaged or broken.

- Fire extinguishers are damaged, do not have the proper inspection tag, blocked, or obstructed, or rendered unavailable to immediate use.

- Exit path is blocked, or obstructed. Exit stairs have any materials or supplies, or debris in stairwell.

- Exit door at bottom of stair is obstructed, or nonfunctional, unable to be easily opened.

- Exit stairs lighting is not operational, areas of the stair are dark or not visible.

- Corridors have trash, debris, or other materials obstructing any part of corridor. Supplies, equipment, materials, and/or waste materials are in corridors.

- Fire and smoke doors are damaged, broken, or unable to close fully, and latch appropriately. Closers do not function fully to close doors.

- Fire and smoke doors are blocked, or obstructed by materials, equipment or wedging

- Trash, debris or other combustible materials stored in rooms or areas adjacent to the corridor.

- Construction materials or equipment storage obstruct the corridor, exit path, stairs, or other use areas.

- Fire separations have holes or penetrations, or unprotected openings.

- There are holes in walls, floors, or fire separations, or other visible changes in the building fire construction that could cause injury or risk to patients or staff.

- Exit lights or illumination of the corridor is burned out, or not operating properly.

FIRE WATCH INSPECTION FORM – EVERY 15 MINUTES

Work Permit #: Fire Department Notification Start Date: Time: Fax #:

Fed Fire POC:

Notified By: Area Covered by Fire Watch:

PRINT NAME OF INSPECTOR (in box next to the time)

Date/Time Day ( ) / / 0630 1245 1900

0015 0645 1300 1915 0030 0700 1315 1930 0100 0715 1330 1945 0115 0730 1345 2000 0130 0745 1400 2015 0145 0800 1415 2030 0200 0815 1430 2045 0215 0830 1445 2100 0230 0845 1500 2115 0245 0900 1515 2130 0300 0915 1530 2145 0315 0930 1545 2200 0330 0945 1600 2215 0345 1000 1615 2230 0400 1015 1630 2245 0415 1030 1645 2300 0430 1045 1700 2315 0445 1100 1715 2330 0500 1115 1730 2345 0515 1130 1745 2400 0530 1145 1800 0545 1200 1815 0600 1215 1830 0615 1230 1845

Notification for fire or other emergencies: cell phone - dial 911: land line - 9-911 and pull fire alarm

Any of the following conditions MUST be reported immediately and corrected

- There is fire, smoke, or a strong smell of smoke, or other evidence of a fire or incipient fire PULL ALARM.

- Fire alarm pull stations, smoke or heat detectors are blocked, obstructed, or rendered inaccessible.

- Fire alarm pull stations, smoke or heat detectors, bells or other fire alarm elements are damaged or broken.

- Fire extinguishers are damaged, do not have the proper inspection tag, blocked, or obstructed, or rendered unavailable to immediate use.

- Exit path is blocked, or obstructed. Exit stairs have any materials or supplies, or debris in stairwell.

- Exit door at bottom of stair is obstructed, or nonfunctional, unable to be easily opened.

- Exit stairs lighting is not operational, areas of the stair are dark or not visible.

- Corridors have trash, debris, or other materials obstructing any part of corridor. Supplies, equipment, materials, and/or waste materials are in corridors.

- Fire and smoke doors are damaged, broken, or unable to close fully, and latch appropriately. Closers do not function fully to close doors.

- Fire and smoke doors are blocked, or obstructed by materials, equipment or wedging

- Trash, debris or other combustible materials stored in rooms or areas adjacent to the corridor.

- Construction materials or equipment storage obstruct the corridor, exit path, stairs, or other use areas.

- Fire separations have holes or penetrations, or unprotected openings.

- There are holes in walls, floors, or fire separations, or other visible changes in the building fire construction that could cause injury or risk to patients or staff.

- Exit lights or illumination of the corridor is burned out, or not operating properly.

Infection Control Construction Permit Version April 2019

INFECTION CONTROL CONSTRUCTION PERMIT

Location of Work (Base/Bldg #): Work Permit #:

Start Date: Est. Duration: Expiration Date:

IC Coordinator/Phone #:

Project POC: Phone #:

FMD POC/Phone #:

KTR Performing Work: Phone #:

KTR Supervisor POC: Phone #:

Construction Activity (Select Only One) Infection Control Risk Group (Select Only One) ☐ 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 greater 1 work shift for completion ☐ GROUP 3: Medium/High Risk

☐ TYPE D: Major duration and construction activates requiring consecutive work shifts ☐ GROUP 4: Highest Risk

CLASS I

1. Infection Control permit posted at job site, printed from WPA.

Facility Manager or FMD Project Manager to coordinate posting at jobsite and with contractor.

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

3. Immediately replace ceiling tile displaced for visual inspection.

4. Clean work area upon completion of work

5. Wipe down all carts and equipment after project is completed with an approved disinfectant, including cart wheels.

6. Cover all carts with tight-fitting cover during transportation to and from work site.

7. Remove PPE before leaving work area (including: gloves, respirators, Tyvek) DATE:

INITIAL:

CLASS II

1. CLASS I REQUIREMENTS including:

2. Provide active means to prevent air-borne dust from dispersing into atmosphere.

3. Water mist work surfaces to control dust while cutting.

4. Place sticky mate at all entrances and exits of work area.

5. Wipe surfaces with EPA approved disinfectant.

6. Contain construction waste before transport in tightly covered containers

7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area end of shift and at completion of project. Spare HEPA filter at jobsite.

8. Visually inspect and repair containment for breaches.

9. Isolate HVAC system in areas where work is being performed to prevent contamination of the duct system: restore when work completed.

DATE:

INITIAL:

CLASS III

1. CLASS I & II REQUIREMENTS including:

2. Obtain infection control permit from Infection Control before construction begins; Post at entrance of containment and in required contractor jobsite documentation.

3. Complete all critical barriers or implement control cube method per Infection Control instruction.

4. Seal unused doors with duct tape.

5. Exhaust per Infection Control Instruction.

6. Vacuum work area with HEPA filtered vacuum.

7. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units (NAM). Manometer at door of containment with a maintained range of 0.01-0.04 inches of water.

8. Wet mop with cleaner/disinfectant.

9. Do not remove barriers from work area until complete project is thoroughly cleaned by contractor AND inspected and approved by Infection Control Representative.

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

DATE:

INITIAL:

CLASS IV

1. CLASS I, II & III REQUIREMENTS including:

2. Construct anteroom; Maintain supplies to fix breaches, extra PPE, hand sanitizer, trash bags, HEPA vacuum with extra filters, and extra secondary filter for the NAM.

3. Visually inspect and repair containment for breaches, including sealing holes, pipes, conduits and punctures appropriately.

4. All personnel entering work site to wear shoe covers.

5. All personnel leaving work sit should vacuum themselves off in the anteroom, using HEPA vacuum and buddy system before leaving containment.

6. For Operating Room (OR) projects: All personnel must also check in at the OR front desk, put on a bunny suit, shoe covers, hair cover, beard cover (if applicable), and wash hands prior to entering sterile core areas.

DATE:

INITIAL:

Infection Control Instruction:

Requested By: Date: Authorized By: Date:

Date: KTR Initial: Date: IC Initial:

Permit Exception/Additions:

Mandatory – Post Construction Containment Inspection (Complete before containment is taken down)

IC Representative approving post-construction containment removal Initials: Date: Time:

☐ FORM IS REQUIRED IF BOX IS “CHECKED”

Infection Prevention Department

Natalie.Gilmore Typewritten Text Work Permit #:

Building Efficiency Division

NMCSD Project

CONTROL # RUF‐ RPIE Real Property Inventory Data Collection Sheet

RUF control number to be filled out by FMD and maintenance contractor

REMOVED AND REPLACED

RPIE ID #: NEW WR #: SO / NTP #: DATE:

RPIE ID #: OLD WR #: SO / NTP #: DATE:

N/A INITIAL

(SELECT ONE) (SELECT ONE)

LOCAL USE: FIELD 1: FIELD 2: FIELD 3: FIELD 4:

N/A INITIAL

SPECS:

N/A INITIAL

INSTALL / MAJOR UPGRADE DATE: LIFE EXPECTANCY: RELATED CAUSE:

POC (TECH): CONDITION DATE: LIFE USED (%):

CONDITION OBSERVATIONS:

N/A INITIAL

N/A INITIAL

PURCHASE ORDER #: VENDOR: POC (FOREMAN):

WARRANTY START DATE: WARRANTY DURATION: PARTS: LABOR:

N/A INITIAL

SUBMITTED BY: DATE: APPROVED BY: DATE:

DAYS/MONTH/YEAR DAYS/MONTH/YEAR

(LENGTH ‐ SELECT ONE) (LENGTH ‐ SELECT ONE)

CATALOG #

5 EXCELLENT 4 GOOD 3 FAIR 2 POOR

MANUFACTURERS INFORMATION

CONDITION INFORMATION (VISUAL OBSERVATION)

(NOT FUNCTIONING / INOPERABLE)(REPAIRS MADE)(NO DAMAGE & PAST WARRANTY)(NEW AND UNDER WARRANTY) (NOT SUPPORTED BY MANUFACTURER)

RPIE ADD/RPIE DELETE/RPIE CHANGE/RPIE NIC

SERIAL #

HERTZ:

1 INOPERABLE

VERSION: 03/19/2018

PART #: ITEM DESCRIPTION:

LOCATION:ITEM I.D. (INSTALL DATE):

MANUFACTURER:

RPM: HP: WEIGHT: CAPACITY:

PARTS

WARRANTY

FLOW RATE:

AMPS: PHASE:

EQUIPMENT HAZARD: AREA SUPPORTED: ROOMS SUPPORTED:

VOLTS:

BREAKER PANEL RM#:

LOW RISK

FEATURES (SPEC DATA)

VERSION #:

INSTALLATION:

SYSTEM:

RISK FACTOR: LIFE SAFETY

NOMENCLATURE:

OTHER LOCATION: ROOM #:

ASSEMBLY:

LIFE SUPPORT INFECT CONTR UTILITY‐HIGH STANDARD RISK

RISK FACTOR CAT CODE: CAT 1‐CATASTROPHIC CAT 2‐CRITICAL CAT 3‐MARGINAL CAT 4‐NEGLIGIBLE

RPIE UPDATE FORM

COOLING CAPACITY: BTU: FREON TYPE: FREON VOL:

WATTS:

SUBSYSTEM:

FACILITY #:

PASS / FAIL / RPR

EQUIPMENT / COMPONENT

(TJC) / BMPNEW / OLD

PSI:

BREAKER PANEL #: BREAKER #:

CLASSIFICATION

INFORMATION CHANGE / ADDEQUIPMENT REMOVED EQUIPMENT ADDED (NIC)

EQUIPMENT / COMPONENT

(RPIE) (SELECT ONE)

ADDRESS:

MODEL: MANUFACTURER:

FILTER SIZE: FILTER TYPE: BELT SIZE: BELT TYPE: FRAME:

FIRE RATING: SERIAL #: FE TYPE: OTHER: OTHER:

x

1/5/2022 3:34 PM

Section 1.6 (n)

BI0 MEDICAL EQUIPMENT INVENTORY LIST

MEDICAL EQUIPMENT LEFT IN CONTAINMENT (NEEDS TO BE FILLED IN

BY DEPARTMENT AND SENT TO BIO MEDICAL DEPARTMENT

BUILDING DURATION OF

CONTAINMENT

LEVEL DATE PREPARED BY

BIOMEDICAL TAG NUMBER MODEL NUMBER DESCRIPTION OF EQUIPMENT LOCATION/DEPARTMENT

INFECTION CONTROL RISK ASSESSMENT (ICRA) CLASS DETERMINATION

STEP 1: Construction Type will be determined using the following guidelines:

TYPE A

Inspection and Non-Invasive Activities (includes, but not limited to):

• Removal of ceiling tiles for visual inspection only, e.g., limited to 1 tile per 50 square feet

• Painting (but not sanding)

• Wall covering or electrical trim work

• Minor plumbing

• Activities which do not generate dust or require cutting walls or access to ceilings other than for visual inspection.

TYPE B

Small scale, short duration activities creating minimal dust (includes, but not limited to):

• Installation of telephone and computer cables

• Access to chase spaces

• Cutting walls or ceilings where dust migration can be controlled

TYPE C

Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components (includes, but not limited to):

• Sanding of walls for painting or wall covering

• Removal of floor coverings

• Ceiling tiles and casework

• New wall construction

• Minor duct work or electrical work above ceilings

• Major cabling activities

• Any activity which cannot be completed within a single work shift

TYPE D

Major demolition and construction projects (includes, but not limited to):

• Activities which requires consecutive work shifts

• Requires heavy demolition or removal of a complete cable system

• New construction

STEP 2. The Infection Control Patient Risk Group will be determined based on the location where the work will take place:

LOW RISK MEDIUM RISK HIGH RISK HIGHEST RISK

• Offices

• Support areas

• Lobbies

• Corridors between

Units/Buildings

• Warehouse

• Cardiology

• Echocardiography

• Endoscopy

• Nuclear Medicine

• PT/OT

• Radiology/MRI

• Respiratory Therapy

• Medical Offices

• Outpatient Clinics (except

Oncology, Transplant and

JMFC)

• Psychiatric Units

• Elevator Areas

• Hospital P-Waves and

Corridors

• ER

• Labor & Delivery (except for

C-sections rooms)

• Laboratories (specimens)

• Nurseries

• Outpatient Surgery

• Pediatrics

• Pharmacy (except IV mix/prep area)

• PACU

• Surgical Units

• Medical Units

• Hemodialysis

• Rehabilitation Units

• Food Service Areas

• Areas with Immuno-compromised Patients-transplant units

• Cardiac Cath Lab

• Central Sterile Processing

• Intensive Care Units (ICUs)

• Oncology/Radiation

Oncology

• Operating Rooms (including

C-Sections rooms)

• Outpatient Clinic (Oncology, transplant, JMFC)

• Pharmacy with IV mix/prep

• Negative Pressure Isolation

Rooms

** B9 – Vivarium is included in the above risk groups based on location within the building **

INFECTION CONTROL RISK ASSESSMENT (ICRA) CLASS DETERMINATION (cont)

STEP 3. Using the following Infection Control Matrix, the risk classification will be determined by Construction Type and Patient Risk Group:

“Construction Type” + “Patient Risk Group” = Containment Class

Patient Risk Group Construction Project Type Type A Type B Type C Type D

LOW I II II III/IV*

MEDIUM I II III IV

HIGH I II III/IV* IV

HIGHEST II III/IV* III/IV* IV

* Signifies it is the discretion of the Infection Prevention Officer to decide whether the project is to be classified a Class III or Class IV containment.

STEP 4. Completion of the WPA with the final Infection Control recommendations. Note: A signed Infection Control Construction Permit (enclosure (a)) is required for ALL Class III and/or Class IV containment before ANY work begins.

References:

Centers for Disease Control and Prevention. Guidelines for Environmental Infection Control in Health-Care Facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). MMWR 2003; 52 (RR10): 1-31.

The American Institute of Architects Academy of Architecture for Health. (2003) Guidelines for Design and Construction of Hospital and Health Care Facilities. AIA. Washington, DC.

The Association for Professional in Infection Control (APIC), Grid Tool, 2005.

Sheet1

Building Efficiency Division

NMCSD Project

CONTROL # RUF- RPIE Real Property Inventory Data Collection Sheet

RPIE UPDATE FORM

EQUIPMENT REMOVED EQUIPMENT ADDED (NIC) REMOVED AND REPLACED INFORMATION CHANGE / ADD

N/A INITIAL CLASSIFICATION

INSTALLATION: FACILITY #: ROOM #: OTHER LOCATION:

SYSTEM: SUBSYSTEM: ASSEMBLY: NOMENCLATURE:

RISK FACTOR: LIFE SAFETY LIFE SUPPORT INFECT CONTR UTILITY-HIGH STANDARD RISK LOW RISK

(RPIE) (CIRCLE ONE) (CIRCLE ONE) (CIRCLE ONE)

LOCAL USE: FIELD 1: NEW / OLD FIELD 2: TJC / BMP FIELD 3: FIELD 4: PASS / FAIL / RPR

N/A INITIAL FEATURES (SPEC DATA)

SPECS: BREAKER PANEL RM#: BREAKER PANEL #: BREAKER #: ADDRESS: VERSION #:

VOLTS: AMPS: PHASE: HERTZ: WATTS:

RPM: HP: WEIGHT: CAPACITY: FLOW RATE:

PSI: COOLING CAPACITY: BTU: FREON TYPE: FREON VOL:

FILTER SIZE: FILTER TYPE: BELT SIZE: BELT TYPE: FRAME:

FIRE RATING: SERIAL #: FE TYPE: OTHER: OTHER:

EQUIPMENT HAZARD:_____________________________ AREA SUPPORTED:_________________________________________ ROOMS SUPPORTED:______________________________

N/A INITIAL CONDITION INFORMATION (VISUAL OBSERVATION)

5 EXCELLENT 4 GOOD 3 FAIR 2 POOR 1 INOPERABLE

(NEW AND UNDER WARRANTY) (NO DAMAGE & PAST WARRANTY) (REPAIRS MADE) (NOT SUPPORTED BY MANUFACTURER) (NOT FUNCTIONING / INOPERABLE)

INSTALL / MAJOR UPGRADE DATE: LIFE EXPECTANCY: RELATED CAUSE: RPIE ADD/RPIE DELETE/RPIE CHANGE/RPIE NIC

POC (TECH): CONDITION DATE: LIFE USED (%):

CONDITION OBSERVATIONS:

N/A INITIAL MANUFACTURERS INFORMATION

MANUFACTURER: MODEL # SERIAL # CATALOG #

N/A INITIAL WARRANTY

PURCHASE ORDER #: VENDOR: POC (FOREMAN):

(LENGTH ) (CIRCLE ONE) (LENGTH ) (CIRCLE ONE)

WARRANTY START DATE: WARRANTY DURATION: PARTS: DAYS MONTHS YEARS LABOR: DAYS MONTHS YEARS

N/A INITIAL PARTS

PART #: ITEM DESCRIPTION:____________________________________________________________

MANUFACTURER:

ITEM I.D. (INSTALL DATE): LOCATION:

SUBMITTED BY: DATE: APPROVED BY: DATE:

VERSION: 12/01/2015

&18&D &T

Sheet2

Sheet3