Information

  • Document No.

  • Project Title

  • Name of Contractor

  • Conducted on

  • Persons present at pre-construction meeting

  • Prepared by

  • Project Title:

  • Start Date:

  • End Date:

  • Project Location:

  • Contractor's Project Manager:

  • Business card:

  • Phone Number:

  • Work Activities:

  • Departments Affected:

  • Above:

  • Below:

  • North:

  • East:

  • South:

  • West:

  • Comments:

Infection Control Risk Assessment (ICRA)

  • Construction Activity Type?<br>

  • 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:

  • Remove isolation of HVAC when approve by LWH project manager or Infection Control

  • Low: Office Areas, CDU, Dietary, Admitting
    Medium: Cardiology, Echocardiography, Nuclear Medicine, Therapy ( PT, OT, ST), Radiology, MRI, Respiratory Therapy, Procedure Rooms.
    High: Emergency Room, Obstetrics, Newborn Nursery, Laboratory, Pharmacy, PACU, Peds Obs, Med-Surg Unit.
    Highest: Operating Room(including C-section), Central Sterile, Oncology, Pharmacy IV Room, NICU, ICU.

  • 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, Highest patient risk group

  • Class I

  • Wet mop and/or Vacuum before leaving area.

  • Immediately replace ceiling tile displaced for visual inspection.

  • 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.

  • 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.

  • Personnel entering area are required to wear shoe covers while in work site. Shoe covers must be removed each time worker exits work area.

  • 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.

  • Contain construction waste in tightly covered containers before transporting.

  • Do not remove barriers until area is inspected by Infection Prevention 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.

  • 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..

  • Place dust mat at entrance and exit of work.

  • Personnel entering area are required to wear shoe covers while in work site. Shoe covers must be removed each time worker exits work area.

  • 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.

  • 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 Prevention 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.

Other Potential Risk

  • Noise?

  • Vibration

  • Air Quality

  • Infection Prevention

  • Emergency Procedures

  • Utility Failures

  • Operational Impact

  • Contractor Access Route

  • Equipment Danger/Risk

  • Additional Requirements:

Signatures/Distribution List/Dates

  • Facilities Management

  • Infection Prevention

  • Contractor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.