Information

  • Conducted on

  • Prepared by

PROJECT INFORMATION

  • Name of Project

  • Location

  • Start Date

  • Estimated Completion Date

  • SHBRH Project Coordinator

  • Name of Contractor Performing Work

  • 24 Hour Contact Number

INFECTION CONTROL RISK LEVEL

  • Select The Risk Level (NOTE: You must refer to the matrix included in the policy)

PENETRATIONS

  • Note: NFPA 101-2000:18/19.3.7.3- all penetrations must be sealed with a fire rated sealer

  • Is this project creating any penetrations?

HOT WORK

  • A "Hot Work Permit" will be required if the project is involving open flames or producing heat and/or sparks. This includes, but not limited to: brazing, cutting, grinding, soldering, torch-applies roofing and welding.

  • Does this project require a "Hot Work Permit"

PERSONNEL ONSITE

  • Please list all sub-contractors (company name and phone number)

  • Please list the names of ALL personnel that will be onsite. Refer to the identification policy of MCMC

PROJECT SPECIFIC ADDITIONAL REQUIREMENTS

FINAL STEP

  • This permit must be completed prior to the start of the project. This permit will be posted at the entrances of the work site.

  • Please select today's date.

  • Please sign your name as the project manager.

  • Email this permit to: construction@mcmcbr.com

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