Information
-
Document No.
-
Project name
-
Site
-
Conducted on
-
Prepared by
Work Activity
-
Enter details of activity
-
Take picture of work area if possible
-
Construction Type
- Removal of Ceiling Tiles for Visual Inspection limited to 1 tile per 50 square feet.
- Painting (But Not Sanding).
- Wall covering, 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.
- Installation of Telephone and Computer cabling.
- Access to chase spaces.
- Cutting of walls or ceiling where dust migration can be controlled.
- 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.
- Activities which Require Consecutive Work Shifts.
- Requires Heavy Demolition or Removal of a Complete Cabling System.
- New Construction.
-
TYPE A - Inspection and Non-Invasive Activities.
-
TYPE B - Small Scale, Short Duration Activities which create minimal dust.
-
TYPE C - Work Generating Moderate to High Level of Dust. Requires Demolition or Removal of Any Fixed Building Components or Assemblies.
-
TYPE D - Major Demolition and Construction Projects.
-
Risk Group That Will Be Affected
- Office Areas
- Not in Patient Care Areas
- Cardiology
- Endoscopy
- Nuclear Medicine
- Physical Therapy
- Radiology/MRI
- Respiratory Therapy
- Dialysis
- CCU
- Emergency Room
- Labor and Delivery
- Laboratories
- Newborn Nursery
- Outpatient Surgery
- Pediatrics
- Pharmacy
- PACU
- Surgical Units
- Any area caring for immunocompromised patients
- Cardiac Cath Lab
- Central Sterile Supply
- Intensive Care Units
- Negative Pressure Isolation Rooms
- Oncology
- Operating Rooms (including L&D OR)
-
Group 1 - Low Risk
-
Group 2 - Medium Risk
-
Group 3 - High Risk
-
Group 4 - Highest Risk
-
Infection Risk Criteria Class.
-
Based on the Construction Type and Risk Group, please select the Risk Criteria from the chart below.
-
Implement the following measures before construction:
1. Execute work by methods to minimize raising dust from construction operations.
2. Immediately replace a ceiling tile displaced for visual inspection -
Implement the following measures before construction:
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. -
Implement the following measures before construction:
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. -
Implement the following measures before construction:
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.
7. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection Control Department and thoroughly cleaned by the owner’s Environmental Services Dept. -
Implement the following measures:
1. Clean work area upon completion of task. -
Implement the following measures:
1. Wipe work surfaces with 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. Remove isolation of HVAC system in areas where work is being peformed. -
Implement the following measures:
1. Do not remove barriers from work area until completed project is inspected by the owner’s Safety Department and Infection 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 disinfectant.
5. Remove isolation of HVAC system in areas where work is being performed. -
Implement the following measures:
1. Remove barrier material carefully to minimize spreading of dirt and debris associated with construction.
2. Contain construction waste before transport in tightly covered containers.
3. Cover transport receptacles or carts. Tape covering unless solid lid
4. Vacuum work area with HEPA filtered vacuums.
5. Wet mop area with disinfectant.
6. Remove isolation of HVAC system in areas where work is being performed -
Additional Requirements:
-
Contractor:
-
Project Manager:
-
Infection Control:
Post Construction
-
Contractor:
-
Project Manager: