Audit

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.
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.