S02 - SOW Att - Ogden elevator 537-21-101 ICRA renewal 6_2025.pdf

Project Title: Project or Work Order Number: MCP 001S-01-28 Appendix C

Updated 2/5/2025 * Asterisk or yellow highlighted item indicate changes added from the VHA Infection Control Risk Assessment for Construction, Renovation and Maintenance instruction VHA ICRA-1.3 (December 2024).

Infection Prevention and Control Construction/Renovation/Maintenance Permit This page must be posted at the entrance to the project area for Level III and Level IV activities.

Unique permit number:

Location Project manager Project start date Contact phone number Estimated Completion date

Contractor Permit expiration date Activity Category (A, B, C, or D)

Overall Patient Risk Category (Low, Medium, High, or Highest)

Level of Infection Prevention and Control Precautions (I, II, III, or IV)

Level of Precautions

Control measures to be in place for the duration of the activity Control Measures)

Level I 1. Perform work activity in a manner that does not create dust.

2. Immediately replace any ceiling tile, close access panels, etc., upon completion of work.

3. Any materials and equipment being brought into the facility must be free of contaminants and loose material.

Level II All control measures in Level I and the following:

1. Provide active means to control airborne dust from dispersing into occupied areas and/or water mist surface to control dust (e.g., Mobile Dust Containment Cart or some other system).

2. Ensure worker clothing is clean and free of visible dust before leaving the work area.

3. Remove or isolate air diffusers (supply and return) to protect the HVAC system from dust and reduce air turbulence. Rebalance system to address diffuser isolation.

4. When the work involves or impacts potable water systems including stagnation due to reduced usage, the piping shall be flushed twice a week or isolated from the main system

5. Seal doors, to prevent dust migration.

6. Contain all trash and debris in the work area. Perform daily cleaning and disposal of trash (covered) from work area using an identified exit route.

7. Any equipment, tools, or materials removed from the work area must be in sealed containers and/or cleaned of dust and debris prior to removal from the area.

8. Nonporous/smooth and cleanable containers (with a hard lid) must be used to transport trash and debris from the construction areas. These containers must be damp-wiped cleaned and free of visible dust/debris before leaving the contained work area.

9. Install a sticky (dust collection) mat at entrance of contained work area based on facility policy. Sticky mats must be changed routinely and when visibly soiled.

10. Maintain clean surroundings when area is not contained by damp mopping or HEPA vacuuming surfaces at least daily.

Level III All control measures in Levels I and II and the following:

1. Ensure availability of equipment for cleaning hands.

2. Construct and complete critical barriers meeting NFPA 241 requirements. Barriers must extend to the ceiling or if ceiling tile is removed, to the deck above.

3. All (plastic or hard) barrier construction activities must be completed in a manner that prevents dust release. Plastic barriers must be effectively affixed to floor and ceiling (or floor/roof deck above) and secure from movement or damage.

4. Seal all penetrations in containment barriers, including floors and ceiling, using approved materials (UL schedule firestop i f applicable for barrier type).

5. Maintain .01 inches /water gauge negative pressurization of the entire workspace by use of HEPA exhaust air systems directed continuously 24/7 for the duration of the project. Exhaust discharged directly to the outdoors that is 25 feet or greater from entrances, air intakes and windows is not required to be HEPA-filtered. Exhausting discharged air into shared or recirculating HVAC systems, or other shared exhaust systems (e.g., bathroom exhaust) is prohibited.

Check box to indicate exhaust method: Exterior Alternative Interior Method

6. Install a differential pressure sensing device (e.g., magnehelic, manometer, or digital monitoring) on exterior of work containment not acceptable.

Level IV All control measures in Levels I, II and III and the following:

1. Barriers must be hard barriers unless temporary to install final barrier.

2. Containment must include an anteroom to ensure pressure control, Anteroom must be large enough for equipment staging, cart

PPE, and cleaning.

3. Worker clothing and/or PPE must be removed or clean and free of visible dust before leaving the work area anteroom. HEPA vacuuming of clothing or use of cover suits is acceptable.

4. Workers must wear shoe covers or have a method to clean shoes in anteroom Shoe covers must be removed prior to exiting the anteroom to the occupied space (non-work area). Damaged shoe covers must be changed immediately.

Additional requirements:

Project Manager/COR signature Date

Infection Preventionist signature Date

PERMIT VALID FOR ONE YEAR FROM THE INFECTION PREVENTIONIST SIGNATURE DATE.

537-21-101Rehab Ogden elevators

Ogden Marcin Nosal

ETI

7/15/24 12/5/25

D LOW III

(773)886-2098

VHACHSNosalM Rectangle

VHACHSNosalM Rectangle

VHACHSNosalM Typewritten Text 6/16/25