152732.00 SECTION 013300

SUBMITTAL PROCEDURES

SUBMITTAL PROCEDURES 013300-10

Agreement for use of Digital Data

Project Name:

Boulder Associates Project Number:

Recipient:

Drawings Requested:

Digital Format Requested:

By accepting this information you are acknowledging that the enclosed electronic media (and hard copy, if any) are provided at your request for the above referenced project. They are also provided for the purpose of expe-diting input of information into the recipient’s computer. In using it, modifying it or accessing the information about it, you are responsible for confirmation, accuracy and checking of the data from the media against that contained on the duplicate hard copy, if any. Boulder Associates hereby disclaims any and all responsibility from any results obtained in use of this electronic media and does not guarantee any accuracy of the infor-mation. Recipient hereby assumes full responsibility for comparing the electronic media information to the hard copy and immediately notifying Boulder Associates in writing of any observed discrepancies.

The information provided by Boulder Associates shall not be used for any purpose other than for the project de-scribed above and shall not be released to any other party without the written consent of Boulder Associates.

The information contained on the electronic media is an instrument of professional services and shall remain the property of Boulder Associates.

Contractor’s Signature Date

Section: Special Procedures 01 35 00 Reviewed Date: 12/2016

Subject: Contractor Conduct on Site

Approval: Page 1 of 4

01 35 00 Special Procedures Contractors

VCLC is committed to providing safe, effective care to our residents at all times. There are a number of issues that must be addressed with administrative, clinical, and facilities management staff. Contractors are required to work with appropriate members of our staff to assess the potential impact of work on the ability to meet the needs of residents and care givers. The risks identified will be used to develop a plan designed to minimize disruption of resident care. VCLC will also make every effort to minimize disruption of the construction process. However, in all cases, resident care considerations will have the highest priority. The State will not compromise resident care or their safety.

1. All tools, equipment, and other construction materials are not to be left unattended at any time; these items may present a danger to residents and staff. Please count all tools prior to entering a unit and then again when leaving. Notify a staff member on the unit immediately if any tool or equipment is missing.

2. The contractor shall remove all construction debris from the site and dispose of it at their expense. Use of the facilities dumpsters is prohibited. All areas are to be kept clean at all times; scrap materials present a danger to residents and staff.

3. Keep DFM Project Manager and the Facility Manager, fully informed of areas to be worked in, changes in work areas, and schedule, etc.

4. Work hours are 8:00 AM to 6:00 PM. Work outside of these hours may be granted with prior authorization of the Administrator.

5. All parking lots are State Property. As such, the Owner reserves the right to search any vehicle parked there and any vehicle entering or leaving the facility. This is a warrantless search; the Owner does not need a warrant to search a vehicle. Workers shall take personal responsibility to search their own vehicles to ensure no articles therein are declared contraband. Examples include guns, knives, bullets, narcotics, and medications (prescribed or otherwise).

6. Any worker taking prescribed medications must bring it in the original prescription container.

7. Smoking/tobacco use is allowed in designated areas only

8. When a contractor is selected to perform demolition, renovation, modification, or other construction services, a team of qualified members of the general contractor, sub-contractors, design professionals, and CDHS staff will assess the impact on operations. A Pre Construction Risk Assessment (Form 01 35 00a) will consider the potential for disturbance of dust that could cause respiratory irritation, infections, or expose anyone to hazards such as asbestos or hazardous chemicals. The noise and vibration associated with construction operations and the potential for impact on the ability to provide resident care or perform normal business functions will be evaluated as well as the potential disruption of utility services and communication systems, the impact on fire and life safety, the security program and systems impact and finally, each project will be carefully reviewed to determine if there are unique problems requiring special consideration during construction.

Approval: Page 2 of 4

The Pre Construction Risk Assessment, Site Incident Prevention Plan (SIPP Form 01 35 23), Infection Control Construction Permit (Form 01 35 33) and ILSM Project Assessment Tool (Form 0135 13b) may all be used to develop plans/schedules to minimize the impact of construction on resident care and business operations of each VCLC. The risk assessment process will be repeated as often as necessary to assure effective management of the issues listed. Contractors must recognize that the impact can vary from day to day. This will require flexibility.

The Centers for Medicare & Medicaid Services (CMS) requires the State to document each risk assessment, the plans developed to manage the impact of construction, and implementation of the plans. Contractors may be required to participate in the documentation of compliance. They are required to participate in implementation and enforcement of the plans. This may include training of staff and sub-contractors, supplying specialized equipment to create or maintain environmental conditions, monitoring staff behavior, and enforcing safe work practices.

9. Any work that impacts utility systems, life safety systems including exiting and egress, shall be scheduled through DFM and the Facility Manager. Written notice will be required for shutdowns of utility systems or life safety systems (Form 01 35 16). Where indicated, Interim Life Safety Measures will be implemented, (Form 01 35 13b).

10. Read and sign the HIPAA Confidentiality Statement (Form 01 35c).

11. Background check. All contractors shall submit a list of employees within five (5) days prior to appearance on site, including full name, date of birth, social security number, and a photocopy of their driver’s license, all of which will be used to conduct a background check.

Any record indicating felony violations, questionable character, or possible security risk shall be just cause for denial of access to the facility. All contractors shall submit a list of employees within four (4) days prior to appearance on site, including full name, date of birth, social security number, and a photocopy of their driver’s license, all of which will be used to conduct a background check. The Security Background Information Sheet (Form 01 35 53) may be completed for each subcontractor and their employees that will be on site

12. The Home will issue Contractor badges will be issued once clearance has been granted.

Badges are required to be worn by contractors for the duration of the project.

1. Keys will be checked out through the Facility Manager. The general contractor is responsible for all keys checked out and their use. If lost or stolen, there will be a charge for the keys and the cost of changing all associated locks.

2. Use caution when entering and exiting memory care units to prevent residents leaving the unit.

3. Do not open doors to allow residents off or on memory care units; residents may be unable to care for themselves or may present a danger to themselves or others if unsupervised.

Notify Charge Nurse and/or Supervisor of any problems related to residents.

Approval: Page 3 of 4

4. Do not leave unattended any unlocked exits or windows. Keep secure or attended other openings from the units that have been created during repair or construction projects at all times.

5. Please be courteous and polite to the residents, such as saying “Good Morning,” “Excuse me,” etc., when appropriate.

6. Report any problems you have with residents to the staff on duty immediately.

7. Do not talk to people outside of the hospital about individual residents; the residents’ care and treatment at the hospital is confidential.

8. Do not bring alcohol or drugs onto the grounds.

9. Team Leaders or Charge Nurses may notice other items that could pose a problem. They will advise you of what may pose that problem and ask you to correct the matter.

10. Proper safety procedures are to be followed at all times to maintain the level of life safety from start to finish of job. Safety measures include, but are not limited to barricades, warning signs and devices, safe equipment and tools, safe working environment, and safe working habits.

11. Possession of Weapons.

Definitions:

a. Any metal tube device constructed for firing projectiles by the force of an explosion by compressed air, or a spring, together with its stock and other attachments. This includes, but not limited to, pistol, revolver, rifle, shotgun, air gun, gas operated gun or spring gun, pellet gun, B.B. gun, any assortment of handguns, etc.

b. Any type of device constructed in a configuration that can be used to inflict injury.

This includes, but is not limited to, any knife having a blade of greater than three and one-half inches (3 1/2) in length; knife or instrument having the appearance of a pocket knife, the blade or blades of which can be opened by a flick of a button, pressure on the handle, or other mechanical contrivance; sling shot, bows and arrows, nunchaks, saps, brass knuckles, artificial knuckles of any substance whatsoever, or any other dangerous or deadly weapons. This shall include weapons commonly known as "peashooter", "slingshot", or "beany", or any instrument made for the purpose of throwing or projecting missiles of any kind by any means whatsoever, whether such instrument is called by any name set forth herein or by any other name.

c. Incendiary or Explosive Device: An incendiary or explosive device shall include, but not limited to, any device consisting in whole or in part of flammable material or other material having the capability of exploding, igniting, or burning.

Contractors are prohibited from having weapons as described above on their person, unsecured or displayed in their vehicles while on the grounds of any Colorado Veterans Community Living Center.

Approval: Page 4 of 4

Any law enforcement officers are authorized to take weapons onto the units only in emergency situations unless the clinical team and the Administrator have made prior arrangements to ensure everyone's safety. Officers shall be asked to surrender their weapons to Administration for safe holding, or may be escorted to a safe non-resident area in non-emergency situations. Other Law Enforcement Officers while performing routine duties may be asked to secure their weapons in their vehicle or in a Weapon Lock Box.

End of Special Procedures

Reviewed Date: December 2016

Subject: Pre Construction Risk Assessment

Approval: Page 1 of 1

01 35 00a Pre-Construction Risk Assessment

CVCLC

Assessment of the Impact of Construction Projects

Category Factors Evaluation

Noise Impact, duration

Air / Dust Cutting, Grinding, Sanding, etc.

Vibration Tool use, demolition, distance

Disruption of utilities Planned shutdowns, Construction near utility system supplies

Life Safety impact ILSM Issues: [1]

Security Site security, access control

Infection Control Category of Risk: [2]

1 – 2 – 3 – 4 – 5

Emergency Services Obstruct access to ambulance/ fire dept.?

[1] ILSM Risk Assessment is useful in determining whether ILSM are necessary and which ILSM are to be used.

[2] Infection Control Risk Assessment is useful for evaluation of the level of practices necessary to provide appropriate levels of patient safety.

Brief description of work to be performed:

Construction Management Plan Elements List areas of forecasted concerns and appropriate measure(s) recommended limiting disruption / code violation / potential adverse outcome.

Project: Location(s):

Start Date:

End Date:

Project Coordinator:

Contractor:

Section: LIFE SAFETY 01 35 13b

Subject: Interim Life Safety Measures-Project Assessment Tool Approval: Page 1 of 1

01 35 13b ILSM-Project Assessment Tool

Interim Life Safety Measures Assessment

These criteria are used to evaluate areas in which construction renovation or repair activities are planned or in which a Life Safety Code deficiency has been identifies. Consideration should be given to the scope of operations in the area, the level of staff activity, and the acuity of patient treatment in the area.

Project: Area:

Date Assessed: PFI Unique ID#

Criteria Not Significant

Significant Findings / Comments ILSM

The issue alters or significantly compromises exit access, exiting, or exit discharge building elements

Significant compromise of building compartmentalization including fire or smoke walls, floor / ceiling assemblies, corridor walls, use area doors, or other defend in place elements

The issue impairs the building fire alarms or sprinkler systems for more than 4 hours in a 24-hour period.

The activity includes significant ignition sources such as cutting, welding, or other operations using flame or producing sparks.

The activity includes large quantities of combustible materials, flammable materials, or generation of large amounts of dust and debris.

Other Factors:

Findings: [ ] ILSM are required [ ] ILSM are not necessary

Assessed by: _ ____________________________________________

Section: LIFE SAFETY 01 35 13.b1

Subject: ILSM Monitoring Form

01 35 13b1 ILSM Monitoring Tool

Interim Life Safety Measures Monitoring Form

Project: _____________________________________

Measure Required Status Date/ Initials

Y N

1.

Exits are inspected on a daily basis and are free and unobstructed. No construction materials, equipment, or debris block free use of all exits adjacent to the construction site or are impacted by the project.

Temporary exit signs are in place.

2.

Provide temporary, but equivalent fire alarm and detection system.

3.

Provides additional fire-fighting equipment (fire extinguishers). Equipment is functional and tests are up to date.

4.

Temporary construction partitions are smoke tight, or made of noncombustible material, or made of limited combustible material that will not contribute to the development or spread of fire.

5.

Surveillance is increased of buildings, grounds, and equipment with special attention to construction areas and storage, excavation, and field offices.

6.

Enforces storage, housekeeping, and debris removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

7.

Additional training is provided to those in the hospital on the use of fire-fighting equipment.

8.

One additional fire drill per shift per quarter is conducted.

9.

Temporary systems are tested and inspected monthly, and the completion dates for these tests is documented.

Education is conducted to promote the awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

Training for those who work in the hospital is done to compensate for impaired structural or compartmental features.

Section: LIFE SAFETY LS.01.02.01EP3a Reviewed Date:12/2008

Subject: ILSM Policy & Criteria

Approval: Page 1 of 4

01 35 13b2 Policy on ILSM & Criteria

Colorado Veterans Community Living Centers Interim Life Safety Measures Program

POLICY

It is the policy of the CVCLC to assure the safety of all building occupants during periods of construction or when significant deficiencies compromise the level of life safety protection provided by the building.

The Life Safety Standards will be evaluated on all construction projects using the following criteria:

1. Ensure exits provide free and unobstructed egress. All personnel will receive training if alternative or temporary exits are designated, especially during construction.

2. Ensure free and unobstructed access to emergency departments or services, and for the emergency personnel.

3. Ensure the fire alarm detection and suppression systems are not impaired. A temporary but equivalent system/plan must be provided when any fire system is not working. Temporary systems must be inspected and tested each month and appropriate documentation should accompany each inspection and test.

4. Ensure temporary construction partitions are smoke tight and are built

i. with non-combustible materials.

5. Provide additional fire extinguishers and user-training for personnel as an ILSM when necessary.

6. Ensure smoking is prohibited in all construction and adjacent areas. Verify enforcement of the no smoking policy and report all incidents of non-compliance to appropriate personnel.

7. Develop and enforce storage, housekeeping, and debris-removal procedures to reduce the flammable and combustible fire load to the lowest level necessary for daily operations.

8. Conduct additional fire drills as an ILSM, when necessary, with a minimum of two per shift per quarter.

9. Increase hazard surveillance of building, grounds and equipment. Areas of special concern are excavating areas, construction areas, construction storage areas, and field offices.

Approval: Page 2 of 4

10. Train DFM, Housekeeping, and Safety personnel to recognize when structural or compartmentation features of fire safety are compromised and what steps to follow to correct the situation.

11. Provide training in hospital-wide safety programs to develop awareness of any life safety deficiencies and construction hazards.

PURPOSE

Interim Life Safety Measures (ILSM) are administrative actions taken to temporarily compensate for the hazards posed by construction activities.

Implementation of the ILSM is required in or adjacent to all construction areas. ILSM apply to all personnel, including construction workers and must be implemented upon project development, and continuous enforced through project compliance.

Interim Life Safety Measures (ILSM) are intended to provide a level of safety comparable to that described in NFPA 101 Life Safety Code 2015.

PROCEDURE

Whenever construction occurs at a VCLC, the DFM Project Manager will conduct routine inspections of the construction sites. If, during these inspections, it is determined that the construction affects the facility’s ability to protect occupants from fire or the products of combustion Interim Life Safety Measures (ILSM), will be implemented as follows:

2. Ensure all exits remain clear. This includes areas directly affected as well as all other exits.

2. Ensure free access to emergency services (i.e. vehicles, materials, etc., are not blocking the access route or parking areas.)

1. Check for the disabling of the fire protection systems. A small disaster could escalate if the fire protection system is not functional. An alternate system must be provided any time the primary system is off-line for a period greater than 12 hours.

2. Fire alarm, detection, and suppression systems must not be impaired. A temporary (but equivalent) system shall be used if the system is impaired.

These systems must be tested monthly.

3. NOTE: If the fire alarm or fire sprinkler system are disabled for four or more hours in a 24 hour period, a fire watch will be implemented and documented.

Approval: Page 3 of 4

01 35 13b2 Policy on ILSM & Criteria

When the life safety system impairment is a result of a construction project, it will be the responsibility of the contractor and the Project Manager to arrange for and document the fire watch and any other appropriate ILSM measures. When the system impairment is a result of system malfunction or other cause, the Safety Department will coordinate ILSM responsibilities including fire watch activities involving program staff and work with DFM to ensure that the problem is corrected as soon as possible.

4. Assure temporary construction partitions are smoke tight and constructed from non-combustible materials. Adequate signage shall discourage casual observers from opening or entering the partitions.

5. The contractor shall provide sufficient fire-fighting equipment to cover all areas of new construction and provide additional fire-fighting equipment in all areas being renovated.

6. Smoking is prohibited in and adjacent to all construction areas. Strict enforcement of this policy will occur.

7. The construction site(s) will be kept clean and orderly. Materials will not be stored in the corridors. The construction crews will remove all waste and debris at the end of each workday. The construction crews will keep construction offices and break areas clean.

8. A minimum of two documented fire drills per shift per quarter (six per quarter) must occur in the construction zone, areas adjacent to the construction zones, and other areas affected by re-routing of exits. A report should be presented to the Safety Committee confirming and evaluating the drills, including recommendations and/or follow-up.

9. Hazard surveillance by DFM and Safety personnel of the construction site shall be increased and documented. Attention is to be given to evacuation routes, construction areas, storage, office/lunch areas, and fuel storage.

10. Whenever the safety of adjacent areas is compromised because of construction, the appropriate staff shall be informed. Alternate exit routes shall be identified and the staff informed.

11. For areas where construction is occurring, department specific education programs covering all employees are to be conducted explaining interim life safety matters and current life safety deficiencies. This is the responsibility of the Department Directors.

12. The construction site must be restricted from all but authorized staff. Adequate signage shall be provided, including indications of a “hard hat” area.

Approval: Page 4 of 4

13. Alternate access must be provided for public and emergency traffic whenever a disruption occurs.

14. Ensure that roads and pathways are clear of snow, materials, etc.

15. Proper notification must be made to local authorities (fire, police, other) whenever life safety is diminished.

16. Construction workers must be made aware of egress routes.

17. Construction workers’ egress routes must be inspected daily to ensure no obstacles.

18. Effective storage, housekeeping, and debris removal policies and procedures must be in place to reduce collection of combustibles in construction areas.

19. Whenever fire zones are altered, appropriate staff (Safety, DFM, Telephone

Operators, and the department affected) are trained in regard to new or different life safety measures regarding their changed compartmentalization of the fire zones and any new fire safety measures.

20. The contractor addresses safety at each construction meeting and it is shown through documentation that the contractor’s staff adheres to safety measures.

21. All welding, brazing, and soldering shall take place only in designated areas where the risk of combustion due to sparks has been minimized. Notification must be given Facility Managers prior to the start of these activities’ beginning.

4112 South Knox Court, Denver, CO 80236 P 303.866.7201 F 303.866.7215 www.colorado.gov/cdhs

HIPAA CONFIDENTIALITY STATEMENT

In order to comply with the Health Insurance Portability and Accountability Act (HIPAA), it is the policy and practice of Colorado Department of Human Services (CDHS) and the Division of Facilities Management that all patient and/or client information, including the identity of individuals, in CDHS facilities is held in strict confidence. It is also the policy that all visitors, vendors or contractors sign this affidavit indicating agreement with its stipulations.

I agree to maintain the confidentiality of all patient/client information (Protected Health Information – PHI), whether in paper, electronic, verbal, or other format, including the identity of any individuals who occupy CDHS facilities. Breach of confidentiality is described as conveying information on any aspect of any patient’s treatment or identity, in all settings, to anyone outside the CDHS facility. This includes any patient and/or client by name, address, telephone number or social security number, or any other identifying information. Protected Health Information may not be shared, without the patient’s/client’s authorization and then only with those having a direct need for such information and as allowed under the CDHS HIPAA Privacy Rule. This is in accordance with the CDHS Policies and Procedures; Confidentiality of Alcohol and Drug Abuse Records, 42 CFR, Part 2, and the Final CDHS HIPAA Privacy and Security Rules.

I have read this Confidentiality Statement and understand and concur.

Signature Date/Time

Printed Name

Firm

Section: Managing Construction EC02.06.05 EP1g Reviewed Date: 10/2011

Subject: Fire Safety Assessment

01 35 16 Fire Safety Assessment

Project Name Location

Date Contact Telephone

Criteria Not Significant

Significant Findings / Comments ILSM

The issue alters or significantly compromises exit access, exiting, or exit discharge building elements

Significant compromise of building compartmentalizing including fire or smoke walls, floor / ceiling assemblies, corridor walls, use area doors, or other defend in place elements

The issue impairs the building fire alarms or sprinkler systems for more than 4 hours in a 24-hour period.

The activity includes significant ignition sources such as cutting, welding, or other operations using flame or producing sparks.

The activity includes large quantities of combustible materials, flammable materials, or generation of large amounts of dust and debris.

Other Factors:

Completed by: _____________________________________ Date: _________

Findings: [ ] ILSM are required [ ] ILSM are not necessary

January 2005 Colorado Department of Human Services

Division of Facilities Management

Hot Work Permit

BEFORE INITIATING HOT WORK, CAN THIS JOB BE AVOIDED?

IS THERE A SAFER WAY?

This Hot Work Permit is required for any temporary operation involving open flames or producing heat and/or sparks. This includes, but is not limited to: Brazing, Cutting, Grinding, Soldering, Thawing Pipe, Torch Applied Roofing, and Welding.

INSTRUCTIONS REQUIRED PRECAUTIONS CHECKLIST

1. Shop Supervisor:

a. Verify precautions listed at right (or do not proceed with the work).

b. Complete this Permit.

c. Copy permit, and issue copy to employee doing the job.

d. Employee doing job posts permit at job site.

2. Hot work being done by:

� Employee � Contractor

3. Date ____________________

4. Work Order Number ____________________

5. Location/Building/Floor

6. Nature of Job

7. Name of person doing Hot Work

I verify the above location has been examined, the precautions checked on the REQUIRED PRECAUTIONS CHECKLIST have been taken to prevent fire, and permission is authorized for this work.

Signature (Shop Supervisor)

Permit Expires:

Date: __________ Time: _________ am pm

Emergency Phone Number: __________

� NOTIFY PBX OR OTHER FIRE SYSTEM

MONITOR PRIOR TO HOT WORK

� Available sprinklers, hose streams and extinguishers are in service/operable.

� Hot work equipment is in good repair.

Requirements within 35 ft of work � Flammable liquids, dust, lint, and oily deposits are removed.

� Explosive atmosphere in the area is eliminated.

� Floors are swept clean.

� Combustible floors are wet down, covered with damp sand, or fire resistive sheets.

� Remove other combustibles where possible.

Otherwise protect with fire resistive tarpaulins or metal shields.

� All wall and floor openings are covered.

� Fire resistive tarpaulins are suspended beneath work.

Work on walls or ceilings � Construction is noncombustible and without combustible covering or insulation.

� Combustibles on other side of walls moved away.

Work on enclosed equipment � Enclosed equipment is cleaned of combustibles.

� Containers purged of flammable liquids/vapors.

Fire watch/Hot Work area monitoring � Fire watch provided if potential for other than minor fire.

� Fire watch is supplied with suitable extinguishers or charged small hose.

� Fire watch is trained in the use of fire suppression equipment and in emergency response notification.

� Fire watch may be required for adjoining areas, and above/below hot work site.

� Monitor Hot Work area for _________ hours after the job is completed.

Other Precautions Taken

Section: Managing Construction 01 35 16 Reviewed Date:12/2016

Subject: Utility System Disruption

01 35 16 Utility System Disruption

Date Contact Telephone:

Construction Activity Locations Affected Patient Care Activities Disrupted

Emergency Response Procedure

Utility Systems Affected:

Date of planned shut-down or interruption Fir

Areas Impacted by the Planned

Shut-Down:

Impact of Shut- Down:

Duration of Shut-Down:

Hours

Electrical

Water/ Plumbing

Sewer

Elevators

Natural Gas

HVAC

Fire

Completed by: ____________________________________ Date: _________

(REFER TO MATRIX ON BACK)

CDHS Colorado Veterans Community Living Centers

(SITE INCIDENT PREVENTION PLAN)

SIPP #:

REQUESTER: COMPANY: PHONE:

BUILDING LOCATION / LEVEL SYSTEM:

INSTALL DEMO OTHER

START DATE: FINISH DATE: TIME:

HOT WORK/EEW DATE: HOT WORK/EEW TIME: PANEL ID / CKTS.

DESCRIPTION OF WORK:

SPECIAL EQUIPMENT/TOOLS: (welders, torch, forklift, scaffolds, lifts, scissor lifts, core driller, generators, backhoe, cranes, etc.)

IMPACTIVE RISK AND PRECAUTIONS:

ASSESSMENT/COMMENTS:__________________________________________________________________

IDENTIFY UTILITIES AT RISK OF IMPACT (see below and circle all affected):

Life Safety Emergency repair Construction project

Fire Alarm Electrical Building interior

Fire sprinkler Plumbing Building exterior

Egress change HVAC Facility grounds

POTENTIAL HAZARD (ACID, CAUSTIC, ELECTRICAL SHOCK, PARTICLES/DUST, ETC.):

SAFETY EQUIPMENT REQUIRED (P.P.E., Shepherd’s Hook, Fire Extinguisher, Etc.):

EMERGENCY TELEPHONE NUMBER:

PRINT / SIGN / DATE PRINT / SIGN / DATE PRINT / SIGN / DATE

REQUESTER: PROJECT MANAGER: ITS:

DFM REPRESENTIVE: SAFETY:

(POST PERMIT AT WORKSITE)

01 35 23 SIPP New Form 2-2015

SIPP MATRIX

# ACTIVITIES *MINIMUM MANAGEMENT EXPECTATIONS

All excavation, trenching, and grading.

Includes driving ground rods, posts and stakes.

*SIPP, Trenching/Excavation Plan, including review of as-builts and locates of utilities. Hand digging and pot holing of located utilities require a spotter. As-builts must be updated before backfill. Thaw if necessary.

Changing flow of vehicles or pedestrian traffic

*SIPP, Coordinate with SAFETY and through FAC as necessary.

(includes interior and exterior interruptions)

De-Energizing utilities feeding live critical systems or production tools

*SIPP, Walk with DFM representative and coordinate with all affected area owners.

Any direct mechanical or electrical tie-ins to live systems

*SIPP, Walk with a DFM representative and coordinate with all affected equipment /area representative.

Any shutdown or modification of live LSS, security or fire protection systems

*SIPP, Coordinate with DFM representative as necessary. Also, FAC coordination needed for by pass of Fire Alarm Systems.

6 All crane lifts *SIPP, Lifts over 1000 lbs or over occupied building areas.

Pressure testing of 2” or larger lines including hydro-testing. Pressure testing stainless steel at greater than 150 psi.

*SIPP, Attach detailed work plan for pressure testing. Work plan must include FAC review of any water disposal as a result of Hydro-test.

Concrete coring, saw cutting or sanding.

Note: Includes excavating through walls/floor, or any dust or particle producing activity.

*SIPP, Attach utilities locate, approved design and/or demo procedure. Fire system protected/disabled as necessary.

Activities that will adversely affect operability, output, or performance of

Critical Systems, or equipment.

*SIPP, Walk with system a DFM representative and coordinate with all affected equipment/area representative.

Any activity that involves the breaking of a line that contains or has contained a hazardous material or energy.

*SIPP, Attach approved Line Break procedure and walk system for certification by DFM representative of safe state.

Attach all Pre-Task Plan Worksheets, supporting documentation, and additional permits if applicable to the SIPP Form.

*SIPP FLOW PROCESS:

1. Determine requirements from SIPP Matrix.

2. Fill out the SIPP and attach supporting documentation and permits.

3. Secure signatures as needed; Facilities Project Manager, Facility Manager and/or Ops

Supervisors. (computer rooms, Safety).

4. Send completed form to tana.lane@state.co.us for assignment number.

Section: Infection Control Construction Permit 01 35 33

Approval: Page 1 of 7

01 35 33 Infection control construction permit

Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation

Step One:

Using the following table, identify the

Type of Construction Project Activity (Type

A-D) TYPE A

Inspection and Non-Invasive Activities.

Includes, but is 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) wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

TYPE B Small scale, short duration activities which create minimal dust

Includes, but is not limited to:

installation of telephone and computer cabling access to chase spaces cutting of walls or ceiling 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 or assemblies

Includes, but is not limited to:

sanding of walls for painting or wall covering removal of floorcoverings, 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 workshift.

TYPE D Major demolition and construction projects

Includes, but is not limited to:

activities which require consecutive work shifts requires heavy demolition or removal of a complete cabling system new construction.

Step 1:

Approval: Page 2 of 7

Step Two:

Using the following table, identify the Patient Risk Groups that will be affected.

If more than one risk group will be affected, select the higher risk group:

Low Risk

Medium Risk High Risk Highest Risk

Office areas

Physical Therapy

Respiratory Therapy

Resident Units

Any area caring for immunocompromised patients

Step 2:

Step Three: Match the…

Patient Risk Group (Low, Medium, High, Highest) with the planned … Construction Project Type (A, B, C, D) on the following matrix, to find the … Class of Precautions (I, II, III or IV) or level of infection control activities required.

Class I-IV or Color-Coded Precautions are delineated on the following page.

IC Matrix - Class of Precautions: Construction Project by Patient Risk

Construction Project Type Patient Risk Group

TYPE A TYPE B TYPE C TYPE D

LOW Risk Group I II II III/IV

MEDIUM Risk Group I II III IV

HIGH Risk Group I II III/IV IV

HIGHEST Risk Group II III/IV III/IV IV

Approval: Page 3 of 7

Description of Required Infection Control Precautions by Class During Construction Project Upon Completion of Project

I

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

2. Immediately replace a ceiling tile displaced for visual inspection

1. Clean work area upon completion of task.

II

1. Provide active means to prevent airborne dust from dispersing into atmosphere.

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

3. Seal unused doors with duct tape.

4. Block off and seal air vents.

5. Place dust mat at entrance and exit of work area

6. Remove or isolate HVAC system in areas where work is being performed.

1. Wipe work surfaces with cleaner/disinfectant.

2. Contain construction waste before transport in tightly covered containers.

3. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

4. Upon completion, restore HVAC system where work was performed.

III

1. Remove or Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Contain construction waste before transport in tightly covered containers.

5. Cover transport receptacles or carts. Tape covering unless solid lid.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Department.

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

3. Vacuum work area with HEPA filtered vacuums.

4. Wet mop area with cleaner/disinfectant.

5. Upon completion, restore

Approval: Page 4 of 7

During Construction Project Upon Completion of Project

IV

1. Isolate HVAC system in area where work is being done to prevent contamination of duct system.

2. Complete all critical barriers i.e. sheetrock, plywood, plastic, to seal area from non work area or implement control cube method (cart with plastic covering and sealed connection to work site with HEPA vacuum for vacuuming prior to exit) before construction begins.

3. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

4. Seal holes, pipes, conduits, and punctures.

5. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave work site.

6. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area.

1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Prevention & Control Department and thoroughly cleaned by the owner’s Environmental Services Dept.

2. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.

3. Contain construction waste before transport in tightly covered containers.

4. Cover transport receptacles or carts. Tape covering unless solid lid.

5. Vacuum work area with HEPA filtered vacuums.

6. Wet mop area with cleaner/disinfectant.

7. Upon completion, restore

Approval: Page 5 of 7

Step 4. Identify the areas surrounding the project area, assessing potential impact

Unit Below Unit Above Lateral Lateral Behind Front

Risk Group Risk Group Risk Group Risk Group Risk Group Risk Group

Step 5. Identify specific site of activity e.g., patient rooms, medication room, etc.

Step 6. Identify issues related to: ventilation, plumbing, electrical in terms of the occurrence of probable outages.

Step 7. Identify containment measures, using prior assessment. What types of barriers? (E.g., solids wall barriers); Will HEPA filtration be required?

(Note: Renovation/construction area shall be isolated from the occupied areas during construction and shall be negative with respect to surrounding areas)

Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (e.g., wall, ceiling, roof)

Step 9. Work hours: Can or will the work be done during non-patient care hours?

Step 10. Do plans allow for adequate number of isolation/negative airflow rooms?

Step 11. Do the plans allow for the required number & type of handwashing sinks?

Step 12. Does the infection prevention & control staff agree with the minimum number of sinks for this project? (Verify against FGI Design and Construction Guidelines for types and area)

Step 13. Does the infection prevention & control staff agree with the plans relative to clean and soiled utility rooms?

Step 14. Plan to discuss the following containment issues with the project team. E.g., traffic flow, housekeeping, debris removal (how and when), Appendix: Identify and communicate the responsibility for project monitoring that includes infection prevention & control concerns and risks. The ICRA may be modified throughout the project.

Approval: Page 6 of 7

Location of Construction: Project Start Date:

Project Coordinator: Estimated Duration:

Contractor Performing Work: Permit Expiration Date:

Supervisor: Telephone:

YES NO Construction Activity YES NO Infection Control Risk Group 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 activities requiring consecutive work shifts.

Group 4: Highest Risk

CLASS I

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

Immediately replace any ceiling tile displaced for visual inspection.

Minor demolition for remodeling.

CLASS II

Provides active means to prevent air-borne dust from dispersing the atmosphere.

Water mist work surfaces to control dust while cutting.

Seal unused doors with duct tape.

Block off and seal air vents.

Wipe surfaces with disinfectant.

Contain construction waste before transport in tightly covered containers.

Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.

Place dust mat at entrance and exit of work area.

Remove or isolate HVAC system in areas where work is being performed.

CLASS III

Obtain infection control permit before construction begins.

Isolate the HVAC System in area where work is being done to prevent contamination of the duct system.

Complete all critical barriers or implement control cube method before construction begins.

Maintain a negative are pressure within work site utilizing HEPA equipped air filtration units.

Do not remove barriers from work area until complete project is thoroughly cleaned by Env. Services Dept.

Vacuum work with HEPA filtered vacuums.

Date Wet mop with disinfectant.

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

Initial Contain construction waste before transport in tightly covered containers.

Cover transport receptacles or carts. Tape covering.

Remove or isolate HVAC system in areas where work is being performed.

CLASS IV

Obtain infection control permit before construction begins.

Isolate HVAC system in area where work is being done to prevent contamination of duct system.

Complete all critical barriers or implement control cube method before construction begins. Date

Approval: Page 7 of 7

Initial Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.

Seal holes, pies, conduits, and punctures appropriately.

Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site.

All personnel entering work site are required to wear shoe covers.

Do not remove barriers from work area until completed project is thoroughly cleansed by the Environmental Service Dept.

Vacuum work area with HEPA filtered vacuums.

Wet mop with disinfectant.

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

Contain construction waste before transport in tightly covered containers.

Cover transport receptacles or carts. Tape covering.

Remove or isolate HVAC system in area where is being done.

Additional Requirements:

Date Initials

Permit Request by: “Exceptions/Additions to this permit are noted by attached memoranda” Date Initials

Date: Date:

Section:Managing Construction 01 35 46

Subject: Air Quality Risk Assessment

01 35 46 Air Quality Risk Assessment

Date Contact Telephone

Methods Used

Yes

No

Comments

Barricades sealed - no penetrations

Walk off mats in place, clean

Door frames gaskets, doors closed

Dust caution signs posted

Adjacent ceiling areas intact

Adjacent floor areas clean - no dust tracking

Negative pressure at barricade entrance

All windows and doors closed behind barricade

Negative air machines running

Negative air machines filter clean

Negative air discharge hoses intact

Project area clean, debris removed daily

Debris removed in suitable containers

Work authorized and scheduled

Surrounding area clean

Completed by: _____________________________________ Date: _________________

FIRM: DATE:

ADDRESS:

PROJECT LOCATION: DFM REQUESTOR:

NAME SSN DRIVER'S LICENSE STATE

DATE OF

BIRTH PLACE OF BIRTH RACE SEX HT WGHT EYES HAIR CURRENT PLACE OF RESIDENCE

SECURITY BACKGROUND INFORMATION SHEET

DIVISION OF FACILITIES MANAGEMENT

ALL INFORMATION MUST BE PROVIDED AND TYPEWRITTEN BEFORE PROCESSING

PLEASE ALLOW FIVE (5) WORKING DAYS TO PROCESS. ALL INDIVIDUALS MUST BE APPROVED BEFORE THEY START WORK ON THE JOBSITE!

152732.00 SECTION 014000

QUALITY REQUIREMENTS

QUALITY REQUIREMENTS 014000-1

PART 1 - GENERAL

1.1 RELATED DOCUMENTS

A. Drawings and general provisions of the Contract, including General and Supplementary Conditions and other Division 01 Specification Sections, apply to this Section.

1.2 SUMMARY

A. Section includes administrative and procedural requirements for quality assurance and quality control.

B. Testing and inspecting services are required to verify compliance with requirements specified or indicated. These services do not relieve Contractor of responsibility for compliance with the Contract Document requirements.

1. Specific quality-assurance and -control requirements for individual construction activities are specified in the Sections that specify those activities. Requirements in those Sections may also cover production of standard products.

2. Specified tests, inspections, and related actions do not limit Contractor's other quality-assurance and -control procedures that facilitate compliance with the Contract Document requirements.

3. Requirements for Contractor to provide quality-assurance and -control services required by Architect, Owner, or authorities having jurisdiction are not limited by provisions of this Section.

4. Specific test and inspection requirements are not specified in this Section.

C. Related Sections include the following:

1. Section 012100 "Allowances" for testing and inspecting allowances.

1.3 DEFINITIONS

A. Quality-Assurance Services: Activities, actions, and procedures performed before and during execution of the Work to guard against defects and deficiencies and substantiate that proposed construction will comply with requirements.

B. Quality-Control Services: Tests, inspections, procedures, and related actions during and after execution of the Work to evaluate that actual products incorporated into the Work and completed construction comply with requirements. Services do not include contract enforcement activities performed by Architect

C. Mockups: Full-size, physical assemblies that are constructed on-site. Mockups are constructed to verify selections made under sample submittals, to demonstrate aesthetic effects and, where indicated, qualities of materials and execution, to review coordination, testing, or operation to show interface between dissimilar materials; and to demonstrate compliance with specified installation tolerances. Mockups are not Samples. Unless otherwise indicated, approved mockups establish the standard by which the Work will be judged.

D. Preconstruction Testing: Tests and inspections performed specifically for the Project before products and materials are incorporated into the Work to verify performance or compliance with specified criteria.

QUALITY REQUIREMENTS 014000-2

E. Product Testing: Tests and inspections that are performed by an NRTL, an NVLAP, or a testing agency qualified to conduct product testing and acceptable to authorities having jurisdiction, to establish product performance and compliance with industry requirements.

F. Source Quality-Control Testing: Tests and inspections that are performed at the source, i.e., plant, mill, factory, or shop.

G. Field Quality-Control Testing: Tests and inspections that are performed on-site for installation of the Work and for completed Work.

H. Testing Agency: An entity engaged to perform specific tests, inspections, or both. Testing laboratory shall mean the same as testing agency.

I. Installer/Applicator/Erector: Contractor or another entity engaged by Contractor as an employee, Subcontractor, or Sub-subcontractor, to perform a particular construction operation, including installation, erection, application, and similar operations.

1. Use of trade-specific terminology in referring to a trade or entity does not require that certain construction activities be performed by accredited or unionized individuals, or that requirements specified apply exclusively to specific trade(s).

J. Experienced: When used with an entity or individual, "experienced" means having successfully completed a minimum of five previous projects similar in nature, size, and extent to this Project; being familiar with special requirements indicated; and having complied with requirements of authorities having jurisdiction.

1.4 CONFLICTING REQUIREMENTS

A. Referenced Standards: If compliance with two or more standards is specified and the standards establish different or conflicting requirements for minimum quantities or quality levels, comply with the most stringent requirement. Refer conflicting requirements that are different, but apparently equal, to Architect for a decision before proceeding.

B. Minimum Quantity or Quality Levels: The quantity or quality level shown or specified shall be the minimum provided or performed. The actual installation may comply exactly with the minimum quantity or quality specified, or it may exceed the minimum within reasonable limits.