Information
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Conducted on
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Prepared by
PROJECT INFORMATION
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Name of Project
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Location
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Start Date
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Estimated Completion Date
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Permit Expires
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MCMC Project Coordinator
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Name of Contractor Performing Work
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24 Hour Contact Number
CONSTRUCTION ACTIVITY TYPE
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Select The Construction Activity Type
INFECTION CONTROL RISK GROUP
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Select The Infection Control Risk Group
RISK LEVEL
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Select The Risk Level
RISK LEVEL 1
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1. Executive work by methods to minimize raising dust from construction operations
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2. Immediately replace any ceiling tiles displaced for visual inspection
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3. Minor demolition for remodeling
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Select if this is the correct Risk Level for this project. By selecting this level you are electronically "Initialing" your name that you agree to these procedures
RISK LEVEL 2
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1. Must abide by all Level 1 Requirements
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2. Provide active means to prevent air-borne dust from dispensing into internal atmosphere
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3. Water mist work surfaces to control dust while cutting
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4. Seal unused doors with tape
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5. Wipe work surfaces with disinfectant
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6. Contain construction waste before transport in tightly covered containers
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7. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area
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8. Place dust mat at entrance and exit of work areas
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9. Remove isolation and HVAC system in areas where work is being performaed
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Select if this is the correct Risk Level for this project. By selecting this level you are electronically "Initialing" your name that you agree to these procedures
RISK LEVEL 3
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1. Must abide by all Level 2 Requirements
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2. Isolate HVAC system in area where work is being done to prevent contamination of duct system
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3. Complete all critical barriers before construction begins or implement method
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4. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units
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5. Contain construction waste before transport in tightly covered containers
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6. Covert transport receptacles or carts; tape covers
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7. Place dust mat at entrance and exit of work area
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Select if this is the correct Risk Level for this project. By selecting this level you are electronically "Initialing" your name that you agree to these procedures
RISK LEVEL 4
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1. Must abide by all Level 3 Requirements
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2. Construct anteroom and require all personnel to pass through this room so that they can be vacuumed using a HEPA vacuum cleaner before leaving the work site or they can wear clothe or paper coveralls that are removed each time they leave the work site
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3. All personnel entering work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work area
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4. Do not remove barriers from work area until completed project is inspected by and thoroughly cleaned by Environmental Services
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5. Remove barrier materials carefully to minimize spread of dirt and debris associated with construction
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Select if this is the correct Risk Level for this project. By selecting this level you are electronically "Initialing" your name that you agree to these procedures
PENETRATIONS
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Note: NFPA 101-2000:18/19.3.7.3- all penetrations must be sealed with a fire rated sealer
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Is this project creating any penetrations?
HOT WORK
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A "Hot Work Permit" will be required if the project is involving open flames or producing heat and/or sparks. This includes, but not limited to: brazing, cutting, grinding, soldering, torch-applies roofing and welding.
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Does this project require a "Hot Work Permit"
PERSONNEL ONSITE
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Please list all sub-contractors (company name and phone number)
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Please list the names of ALL personnel that will be onsite. Refer to the identification policy of MCMC
PROJECT SPECIFIC ADDITIONAL REQUIREMENTS
FINAL STEP
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This permit must be completed prior to the start of the project. This permit will also have the Interim Life Safety Plan accompanying it, posted at the entrances of the work site.
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Please select today's date.
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Please sign your name as the project manager.
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Email this permit to: construction@mcmcbr.com
