Saint Francis TEC

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Project Information

• Has pre-construction meeting been held?

  Yes

  No

Equipment Schedule

• Has medical equipment manufacturer been determined?

  Yes

  No

• When is equipment schedule expected to be released?

Unload/Staging

• Has unload/staging area been determined?

  Yes

  No

• Location and description of unload/staging area

• Photo of unload/staging area

  Media

• List of concerns regarding unload/staging

• Who is responsible for determining - when will this be determined?

Area A - Room 16-516

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions (4 items in this room)

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-607

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-610

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed?

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-612

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-615

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-616

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-623

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-626

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-632

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-634

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-636

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-638

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-639

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-641

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-648

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-649

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-650

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-651

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions (2 items in this room)

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area A - Room 16-653

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-102

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-104

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-106

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-108

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-110

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-112

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-114

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-116

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-118

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-120

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-122

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-124

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)

Equipment/Dimensions

• Equipment to be installed? (Only check one)

  Select X-Ray Support Single Light Support Double Light Support Gas Column Cath Support Patient Mover

  • X-Ray Support
  • Single Light Support
  • Double Light Support
  • Gas Column
  • Cath Support
  • Patient Mover

• Manufacturer of equipment

• Model #

• Number of rails?

• Height of finish rails to finish floor?

• Height from finish plate to finish floor height?

• Is Burgess required to supply mounting plate?

  Yes

  No

• Do we have plate dimensions/configuration?

  Yes

  No

• Who is responsible for providing information?

• When do we expect to receive information?

Obstructions/Concerns

• Are there noticeable obstructions?

  Yes

  No

• What type of obstruction(s)? (Can select multiple)

  Select Mech Duct Electrical Fire Sprinkler Other

  • Mech Duct
  • Electrical
  • Fire Sprinkler
  • Other

• What is/are the obstruction(s)?

• Photo of obstruction

  Media

• Is there adequate access to anchor points?

  Yes

  No

• Describe condition and potential solution.

• Photo of condition.

  Media

• Are there items in room that will require protection?

  Yes

  No

• Describe the item and proposed protection.

• Who is responsible for providing and installing protection?

• Photo of item to be protected?

  Media

• Are there other concerns?

  Yes

  No

• What other concerns are there?

• Photo of area of concern.

  Media

Area B - Room 16-126

Installation information

• Structure attachment

  Select Conc - Flat Deck Conc - Joist Conc - Dbl T Steel - I-Beam Steel - Open Web Bar Joist Steel - Castelated Beam Wood

  • Conc - Flat Deck
  • Conc - Joist
  • Conc - Dbl T
  • Steel - I-Beam
  • Steel - Open Web Bar Joist
  • Steel - Castelated Beam
  • Wood

• Is attachment structure within tolerance? (i.e. +/- 1/4" horizontally & vertically)

  Yes

  No

• How far out of tolerance is it?

• Picture of condition

  Media

• What type of equipment will we be installing from?

  Scissor Lift

  Ladder

  Scaffolding

• Can we mark layout of finish rails on floor?

  Yes

  No

Dimensions

• Is room square/rectangular?

  Yes

  No

• Length of room?

• Width of room?

• If room is not square - draw layout of room with dimensions.

  Drawing

• Ceiling height?(from finished floor)

• Spacing between attachment points? (Structure Span?)

• Height from bottom of attachment structure to finished floor?

• Height of interstitial space?(space from attachment point to ceiling)