UMMS ICRA 2.0 Infection Control Risk Assessment and Permit

ICRA 2.0 Infection Control Risk Assessment and Permit

• Project Name:

• ICRA 2.0 Number

• Requested by:

• Location of Work Activity
  Address

• Project Start Date

  Date

• Estimated Duration

  Date

• Estimated Completion Date:

  Date

• Foreman/Supervisor:

• Foreman/ Supervisor Contact Information

• Contractor Performing Work

• Contractor Contact Information

• Approving Authority:

  Sign

• 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

  Select Low I Medium I High I Highest III

  • Low I
  • Medium I
  • High I
  • Highest III

• Type B

  Select Low II Medium II High III Highest IV

  • Low II
  • Medium II
  • High III
  • Highest IV

• Type C

  Select Low II Medium III High IV Highest V

  • Low II
  • Medium III
  • High IV
  • Highest V

• Type D

  Select Low III Medium IV High V Highest V

  • Low III
  • Medium IV
  • High V
  • Highest V

4. Surrounding Area

• Unit

  Select Below: Above: Lateral: Behind: In Front:

  • Below:
  • Above:
  • Lateral:
  • Behind:
  • In Front:

• Risk Group

  Select Below: Above: Lateral: Behind: In Front:

  • Below:
  • Above:
  • Lateral:
  • Behind:
  • In Front:

• Contact

  Select Below: Above: Lateral: Behind: In Front:

  • Below:
  • Above:
  • Lateral:
  • Behind:
  • In Front:

• Phone

  Select Below: Above: Lateral: Behind: In Front:

  • Below:
  • Above:
  • Lateral:
  • Behind:
  • In Front:

• Controls

  Select Noise Vibration Dust Ventilation Pressurization

  • Noise
  • Vibration
  • Dust
  • Ventilation
  • Pressurization

• Systems Impacted

  Select Data Mechanical Med Gas Hot/Cold Water Other

  • Data
  • Mechanical
  • Med Gas
  • Hot/Cold Water
  • Other

• 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

  I

  II

  III

  IV

  V

• 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

  Sign