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ICRA 2.0 Infection Control Risk Assessment and Permit

  • Project Name:

  • ICRA 2.0 Number

  • Requested by:

  • Location of Work Activity
  • Project Start Date

  • Estimated Duration

  • Estimated Completion Date:

  • Foreman/Supervisor:

  • Foreman/ Supervisor Contact Information

  • Contractor Performing Work

  • Contractor Contact Information

  • Approving Authority:

  • Approving Authority Contact Information

  • Please note that the above signature is approval of the work activity as described and assessed documented here. Should the scope of work change or the discovery of additional toxic or biological substances. STOP WORK AND SEEK ADDITIONAL APPROVAL AND GUIDANCE BEFROE PROCEEDING.

1. Type of Activity Explain this reasoning for this assessment

  • Type A: Non Invasive

  • Type B: Small-scale, short duration

  • Type C: Large-scale, longer duration

  • TypeD: Major Demolition

2. Patient Risk Area Describe key patient risks

  • Low: Non-patient care areas

  • Medium: Patient care support areas

  • High: Patientcare areas

  • Highest: Invasive, sterile or highly compromised care

3. Class of Precautions

  • Type A

  • Type B

  • Type C

  • Type D

4. Surrounding Area

  • Unit

  • Risk Group

  • Contact

  • Phone

  • Controls

  • Systems Impacted

  • Were there discoveries in surrounding areas that would serve as cause to increase the class of precautions and necessitate additional? If so, please summarize.

5. Detailed Plan of ICRA Controls for this Work Class I

  • Final Class of Precautions being applied

  • Controls required for this project

  • Specification/Materials

  • Verification method and frequency

Exceptions/Additions to permit Date and Initials are noted by attached memoranda

  • Initials

  • Permit Request By

  • Permit Authorized By

  • Approval Signature

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