VA261-17-B-0515-A00001002.pdf

VA Northern California Health Care System Attachment A Policy Statement 138-56 May 7, 2014, Revision January 7,2017

Infection Control Construction Permit Permit No:

Location of Construction: Bldg. 700, 1st Floor, Mather Project Start Date:

Project COR: Rodney Rickert Estimated Duration: one year Contractor Performing Work: Permit Expiration Date:

Supervisor: Telephone:

YES NO CONSTRUCTION ACTIVITY YES NO INFECTION CONTROL RISK GROUP

I TYPE A: Inspection, non-invasive activity i GROUP 1: Low Risk

1 TYPE B: Small scale, short duration, moderate to high levels

I GROUP 2: Medium Risk

1 TYPE C: Activity generates moderate to high levels of dust, requires greater 1 work shift for completion

1 GROUP 3: Medium/High Risk

TYPED: Major duration and construction activities Requiring consecutive work shifts 1

GROUP 4: Highest Risk

CLASS .I.

Execute work by methods to minimize raising dust from 3. Minor demolition for remodeling.

construction operations.

2. Immediately replace any ceiling tile displaced for visual inspection.

CLASS II

I. Provides active means to prevent air-borne dust from 6. Contain construction waste before transport in tightly dispersing into atmosphere. covered containers.

2. Water mist work surfaces to control dust while cutting. 7. Wet mop and/or vacuum with HEPA filtered vacuum

3. Seal unused doors with duct tape. before leaving work area.

4. Block off and seal air vents. 8. Place dust mat at entrance and exit of work area.

5. Wipe surfaces with disinfectant. 9. Remove or isolate HVAC system in areas where work is being performed.

Date

. Obtain infection control permit before construction 6. Vacuum work begins. 7. Wet mop with

2. Isolate HVAC system in area where work is being done 8. Remove barrier to prevent contamination of the duct system. spreading of

. Complete all critical barriers or implement control cube Contain construction method before construction begins, covered containers.

4. Maintain negative air pressure within work site utilizing 9. Cover transport HEPA equipped air filtration units. 10. Remove or

5. Do not remove barriers from work area until complete being performed.

project is thoroughly cleaned.

with HEPA filtered vacuums.

disinfectant.

materials carefully to minimize dirt and debris associated with construction.

waste before transport in tightly receptacles or carts. Tape covering.

isolate HVAC system in areas where work is

Initial

CLASS TV

1. Obtain infection control permit before construction 7. All personnel entering work site are required to wear begins, shoe covers.

2. Isolate HVAC system in area where work is being done 8. Do not remove barriers from work area until completed to prevent contamination of duct system, project is thoroughly cleaned.

1 3. Complete all critical barriers or implement control cube 9. Vacuum work area with HEPA filtered vacuums.

method before construction begins. 10. Wet mop with disinfectant.

4 Maintain negative air pressure within work site utilizing 11. Remove barrier materials carefully to minimize

HEPA equipped air filtration units, spreading of dirt and debris associated with construction.

5. Seal holes, pipes, conduits, and punctures appropriately. 12. Contain construction waste before transport in tightly

6. Construct anteroom and require all personnel to pass covered containers.

through this room so they can be vacuumed using a 13. Cover transport receptacles or carts. Tape covering.

HEPA vacuum cleaner before leaving work site or they 14. Remove or isolate HVAC system in areas where can wear cloth or paper coveralls that are removed each construction is being done.

time they leave the work site.

Date 12J20/2017

Initial

JSD

Additional Requirements:

Exceptions/Additions to this permit Date Initials

Date Initials are noted by attached memoranda.

Permit Requested By: Rodney Rickert Permit Authorized By:

Date: 12/18/17 Date: