Information
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Document No.
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Project Title
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Work Order #
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Conducted on
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Prepared by
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Location
General Information
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Project:
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Start Date:
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End Date:
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Project Location:
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Contact Person:
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Phone Number:
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Work Activities:
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Departments Affected:
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Above:
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Below:
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North:
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East:
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South:
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West:
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Comments:
Infection Control Risk Assessment (ICRA)
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Containment Area
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Construction Activity Type?<br>
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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:
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Remove isolation of HVAC when approve by NRMC project manager or NRMC infection prevention.
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Low: Office Areas
Medium: Inpatient Units, Outpatient Units, Physical therapy, Radiology,
High: Emergency Room, Obstetrics, Lab/Pharmacy, Same Day Surgery, Cafeteria, Treatment area
Sensitive: Operating Room(including C-section), Central Sterile, Oncology, Pharmacy IV Room, Radiation, Chemo Patient areas. -
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
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Wet mop and/or Vacuum before leaving area.
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Immediately replace ceiling tile displaced for visual inspection.
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Execute work by methods to minimize raising dust from construction operations
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Class II
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Provide active means to prevent airborne dust from dispersing into atmosphere.
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Seal holes, pipes, conduits and punctures appropriately..
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Seal unused doors with tape.
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Block off and seal air vents.
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Place dust mat at entrance and exit of work.
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Isolate HVAC system in areas where work is being preformed.
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Water mist work surfaces to control dust while cutting.
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Contain construction waste in tightly covered containers before transporting.
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Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area.
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Wipe surfaces with disinfectant.
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Remove isolation of HVAC when approve by MMH project manager or MMH infection prevention.
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Class III
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Isolate HVAC system in area work is being performed to prevent contamination of dust system.
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Seal unused doors with tape.
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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.
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Seal holes, pipes, conduits and punctures appropriately..
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Place dust mat at entrance and exit of work.
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Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
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Personnel entering area are required to wear shoe covers while in work site. Shoe covers must be removed each time worker exits work area.
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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.
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Contain construction waste in tightly covered containers before transporting.
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Do not remove barriers until area is inspected by Infection Prevention and thoroughly cleaned by Environmental Services Department.
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Remove barrier materials carefully to minimize spreading of dirt, dust, and debris. Transport in tightly covered & sealed containers.
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Vacuum work area with HEPA filtered vacuums.
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Wet mop area with disinfectant.
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Remove isolation of HVAC when approve by MMH project manager or MMH infection prevention.
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Class IV
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Isolate HVAC system in area work is being performed to prevent contamination of dust system.
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Seal unused doors with tape.
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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.
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Seal holes, pipes, conduits and punctures appropriately..
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Place dust mat at entrance and exit of work.
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Personnel entering area are required to wear shoe covers while in work site. Shoe covers must be removed each time worker exits work area.
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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.
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Contain construction waste in tightly covered & sealed containers containers before transporting.
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Maintain negative air pressure within work site utilizing HEPA equipped air filtration units.
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Do not remove barriers until area is inspected by Infection Prevention and thoroughly cleaned by Environmental Services Department.
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Remove barrier materials carefully to minimize spreading of dirt, dust, and debris. Transport in tightly covered & sealed containers.
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Vacuum work area with HEPA filtered vacuums.
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Wet mop area with disinfectant.
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Remove isolation of HVAC when approve by MMH project manager or MMH infection prevention.
Other Potential Risk
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Noise?
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Vibration
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Air Quality
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Infection Prevention
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Emergency Procedures
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Utility Failures
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Operational Impact
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Contractor Access Route
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Equipment Danger/Risk
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Additional Requirements:
Signatures/Distribution List/Dates
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Facilities Management
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Infection Prevention
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Contractor
