J-1502000-02(DHA)-03_Pre-Construction Site Survey.pdf

Pre-Construction Site Survey External Construction Projects

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work: Telephone:

Supervisor: Telephone:

Description of project:

Construction Activities The following must be addressed prior to the beginning of any construction activities.

• Separation wall must be constructed prior to project beginning.

• Fire protection systems must remain intact.

• Provide extra fire extinguishers in work areas.

• Maintain exit lights in work area.

• Maintain negative air in construction area (24/7) through duration of project.

• There cannot be any return air from within the construction area to the rest of the building.

• Redirect exiting not to go through construction area.

• Put signs on doors into construction area “Construction Area – Do Not Enter”.

• Maintain daily logs and keep a current Hot Work Permit.

• Place sticky mats at doors exiting construction area.

• All debris removal must be by covered cart.

• Maintain clean and orderly work area.

• How will this project affect the departments above, below and adjacent to this project?

Yes No Will there be noise generated that will impact a department adjacent to, above, or below the construction area?

a. If so, these departments must be notified.

b. How are you going to reduce the noise to an acceptable level?

Yes No Will there be vibration generated that will impact a department adjacent to, above, or below the construction area?

a. If so, these departments must be notified each time this type of work will be performed.

b. How are you going to reduce the vibration to an acceptable level?

Yes No Are Emergency Procedures in place and posted on each job for accidental events that could greatly impact Patient Care or Life Safety to the facility? Included in these procedures are such things as:

• Emergency telephone numbers of key departments.

• A plan that describes where main valves, switches, and controls are for the area in case of an emergency.

• A plan for unexpected outages.

Environment

Yes No Are any of the following environmental hazards present?

Will hazardous chemicals be used on this project? If yes, how will fumes and odors be controlled? (MSDS Sheets are required.)

Is asbestos abatement required on this job? If so, proper permits must be obtained.

Will there be hot work done on this project? If so, a hot work permit must be posted on the job site. All hot work must have a fire watch assigned to each area while the hot work is being performed.

Will there be a Confined Space Entry required on this project? If so, the confined space entry program must be followed.

Utility Failures

Yes No Will any of the following systems be out of service at any time during the project?

• Fire alarm (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)

• Sprinkler (If out for more than 4 hours, Interim Life Safety Measures must be implemented.)

• Electrical

• Domestic water

• Oxygen

• Sewage

• HVAC

USNHGBINST 11112.1

USNHGB 11112/02 1

Yes No Will there be any work that will require activation of the Interim Life Safety Measures during this project? Some things that will ILSM’s to be implemented are but not limited to:

• Any construction that impacts an EXIT or stairs,

• Any construction that impacts major breaches in a fire or smoke wall,

• Taking the main fire protection system out of service (sprinkler),

• Taking the main fire alarm system out of service,

• Taking the “area” fire or fire alarm systems out of service for more than 4 hours within a 24-hour period.

Implementation of the ILSM requires a fire watch and the ILSM forms to be completed.

Additional Safety Concerns Yes No

Will construction affect exit routes from occupied areas adjacent to construction site?

Will project affect traffic patterns in area? If yes, explain plan.

Will construction activity affect exiting from a stair?

Will construction affect Fire Department Access?

a. Connection to Siamese connection?

b. Ladder Track rescue access?

Air Quality and Infection Control

Where are the HVAC intakes in relation to construction area? Are PTAC units near construction area?

Has an infection control Risk Assessment been preformed on the impact construction will have on the facility?

The construction activity types are defined by the amount of dust that is generated, the duration of the activity, and the amount of shared HVAC systems.

Yes No

Will dust be generated during this project?

If yes, explain location of and plan for interim dust barriers or attach floor plan with barriers clearly marked.

Do you have a dust control plan in place? Explain

Has the construction manager/contractor been trained on awareness of how the construction activities can/will impact the facility?

Additional Requirements or Concerns:

Building Representative Site Inspection Conducted By Site Inspection Conducted By

Date: Date: Date:

USNHGBINST 11112.1

2USNHGB 11112/02