Audit

General Information

Project:

Start Date:
End Date:

Project Location:

Contact Person:

Phone Number:

Work Activities:

Departments Affected:

Above:

Below:

North:

East:

South:

West:

Comments:

Infection Control Risk Assessment (ICRA)

Containment Area type

Construction Activity Type?

Type A: Inspection and Non-Invasive activity
Type B: Small scale, short duration activities creating minimal dust
Type C: Activity generates moderate to high levels of dust or requires demolition or removal of building components, or requires greater that 1 work shift for completion
Type D: Major demolition or construction activities requiring consecutive work shifts

Patient Risk Group:

Low: Office Areas
Medium: Inpatient units, Outpatient units, Physical Therapy, Radiology
High: Emergency Room, Labor & Delivery, Peds/Newborn, Lab/Pharmacy, Outpatient Surgery, Cafeteria, Treatment Center
Sensitive: Operating Rooms (including C-section), Central Sterile, Cardiac Cath Lab, Oncology/Neuro, ICC, Dialysis, Pharmacy IV Room, Radiation, Chemo Pt's.

ICRA Class
I: Type A work Low, Medium, High patient risk group

II: Type A work Sensitive patient risk group
Type B work Low, Medium, High patient risk group
Type C work Low, patient risk group

III: Type C work medium patient risk group

III/IV: Type B work Sensitive patient risk group
Type C work High and Sensitive patient risk group
Type D work Low patient risk group

IV: Type D work Medium, High, Sensitive patient risk group

Class I

Immediately replace any ceiling tiles displaced for visual inspection

Clean Work Area upon completion of work

Execute work by methods to minimize raising dust from construction operations

Class II

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

Seal holes, pipes, conduits and punctures appropriately..

Seal unused doors with tape.

Block off and seal air vents.

Place dust mat at entrance and exit of work.

Isolate HVAC system in areas where work is being preformed.

Water mist work surfaces to control dust while cutting.

Contain construction waste in tightly covered containers before transporting.

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

Wipe surfaces with disinfectant.

Remove isolation of HVAC when approve by MMC project manager or MMC infection control.

Class III

Isolate HVAC system in area work is being performed to prevent contamination of dust system.

Seal unused doors with tape.

Complete all critical critical barriers, (sheetrock, plywood, plastic) to seal area form 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.

Seal holes, pipes, conduits and punctures appropriately..

Place dust mat at entrance and exit of work.

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

Contain construction waste in tightly covered containers before transporting.

Do not remove barriers until area is inspected by Infection Control Group and thoroughly cleaned by Environmental Services Department.

Remove barrier materials carefully to minimize spreading of dirt, dust, and debris. Transport in tightly covered & sealed containers.

Vacuum work area with HEPA filtered vacuums.

Wet mop area with disinfectant.

Remove isolation of HVAC when approve by MMC project manager or MMC infection control.

Class IV

Isolate HVAC system in area work is being performed to prevent contamination of dust system.

Seal unused doors with tape.

Complete all critical critical barriers, (sheetrock, plywood, plastic) to seal area form 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.

Seal holes, pipes, conduits and punctures appropriately..

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

Personnel entering work area are required to wear shoe covers. Shoe covers must be changed each time worker exits work area.

Contain construction waste in tightly covered & sealed containers containers before transporting.

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

Do not remove barriers until area is inspected by Infection Control Group and thoroughly cleaned by Environmental Services Department.

Remove barrier materials carefully to minimize spreading of dirt, dust, and debris. Transport in tightly covered & sealed containers.

Vacuum work area with HEPA filtered vacuums.

Wet mop area with disinfectant.

Remove isolation of HVAC when approve by MMC project manager or MMC infection control.

Signatures/Distribution List/Dates
Facilities Management
Infection Control
Safety and Security
Contractor
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.