South Austin Medical Center

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Contractor acknowledges proper insurance, certification, licensure

  Yes

  No

  N/A

• Select Yes No N/A

  • Yes
  • No
  • N/A

• Add media

  Media

• Adequate barriers, cones, safety tape in place as necessary.

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

• Add media

  Media

• Ceilings will be closed during breaks, meals, or for any period longer than 30 minutes in duration

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• If tile removed in High Risk areas (ICU, Nursery, NICU, etc.) containment is required

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

• Add media

  Media

• PCRA/ ICRA required

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Map identifying work area(s) submitted prior to permit issuance

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

• Add media

  Media

• Penetrations required/ permit issued

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Dust containment in proper working order with HEPA negative pressure

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Per-existing conditions identified

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Interim Life Safety Measures in place, if necessary

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Contractors trained regarding ILSM

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• No cables or supports on sprinkler pipe

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Contractors aware of egress routes

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

• Add media

  Media

• Disruption to facility kept at a minimum in high-traffic areas

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• All exits clear

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Free access to Emergency Services

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Alternate routes for public and emergency use

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

• Add media

  Media

• Additional firefighting staff and equipment available in conjunction with "Hot Work" permit if performing any work above ceiling

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Smoking is strictly prohibited

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Construction site clean and orderly

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Contractors are informed if adjacent areas affected

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Proper ladders/ scaffolding in use

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Effective site storage of materials and equipment

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Fire zones maintained, contractors aware of changes

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Will there be any Noise and Vibration Risks? (Noise and Vibration Risk Assessment" form required if answered "Yes")

  Yes

  No

  N/A

• Select yes No N/A

  • yes
  • No
  • N/A

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  Media

• Select date

  Date

• Add signature

  Sign

After completion of work, inspections SHALL be scheduled with a representative of Facility Engineering prior to job closure and final approval. Any deficiencies will be corrected by contractor within three (3) business days after notification of deficiency. If no corrective action for the non-compliant work is made, South Austin Medical Center will make the appropriate corrections at market cost ($30.00/ Hr labor, plus material) and invoice the deficient party.

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