INFECTION CONTROL & INTERIM LIFE SAFETY MEASURE
RISK ASSESSMENT
JOB #
Project Title:
Project Coordinator:
General Contractor :
IOR:
Contractor Name:
Project Start Date:
Estimated Completion Date:
OSHPD Permit #:
IC Subcontractor Contact#:
Contact#:
Contact#:
Contact#:
CONSTRUCTION ACTIVITY
TYPE A: Inspection, non-invasive activity
CLASS I
Date:
Initials:
CLASS II
Date:
Initials:
GROUP 1: Low Risk
TYPE B: Small scale, short duration,
moderate to high levels
GROUP 2: Medium Risk
TYPE C: Activity generates moderate to high levels of
dust, requires more than 1 work shift for completion
GROUP 3: Medium/High Risk
TYPE D: Major demolition and construction activities
Requiring consecutive work shifts
GROUP 4: Highest Risk
1.
3.
2.
Execute work by methods to minimize raising dust from
construction operations.
Immediately replace any ceiling tile displaced for visual inspection.
1.
Continue Class I requirements
7.
2.
3.
4.
5.
6.
Provides active means to prevent air-borne dust from dispersing into
atmosphere
Water mist work surfaces to control dust while cutting.
Seal unused doors with duct tape.
Block off and seal air vents.
Wipe surfaces with approved disinfectant.
Contain construction waste before transport in tightly covered
containers.
8. Wet mop and/or vacuum with HEPA filtered vacuum before
leaving work area. Vacuum Personnel if needed.
9. Place dust mat at entrance and exit of work area.
10. Remove or isolate HVAC system in areas where work is being
performed.
1.
Continue Class I & II requirements
8.
2.
3.
CLASS III
Date:
Initial:
INFECTION CONTROL RISK GROUP
4.
5.
6.
7.
1.
Obtain infection control permit before construction begins.
Isolate HVAC system in area where work is being done to prevent
contamination of the duct system.
Complete all critical barriers or implement control cube method
before construction begins.
Maintain negative air pressure within work site utilizing
HEPA equipped air filtration units.
Seal holes, pipes, conduits, and punctures appropriately.
Do not remove barriers from work area until complete project is
thoroughly cleaned.
Cleanup and disposal in accordance with defined procedures.
9.
10.
11.
12.
13.
Vacuum work area with HEPA filtered vacuums including
Personnel, if needed.
Wet mop with approved disinfectant
Remove barrier materials carefully to minimize spreading of dirt
and debris associated with construction.
Contain construction waste before transport in tightly covered
Containers.
Cover transport receptacles or carts. Tape covering.
Remove or isolate HVAC system in areas where work is being
performed.
Continue Class I, II & II requirements
Date
Initial
8. All personnel entering work site are required to wear shoe
covers
Obtain infection control permit before construction begins.
9. Do not remove barriers from work area until completed project is
Isolate HVAC system in area where work is being done to prevent
thoroughly cleaned.
contamination of duct system.
10. Vacuum work area with HEPA filtered vacuums.
4. Complete all critical barriers or implement control cube method
11. Wet mop with approved disinfectant.
before construction begins.
12. Remove barrier materials carefully to minimize spreading of dirt
5. Maintain negative air pressure within work site utilizing HEPA
and debris associated with construction.
equipped air filtration units.
13. Contain construction waste before transport in tightly covered
6. Seal holes, pipes, conduits, and punctures appropriately.
containers.
7. Construct anteroom and require all personnel to pass through
14. Cover transport receptacles or carts. Tape covering.
this room so they can be vacuumed using a HEPA vacuum
15. Remove or isolate HVAC system in areas where work is being
cleaner before leaving work site or they can wear cloth or
done.
paper coveralls that are removed each time they leave the work
site.
IF THE ANSWER IS YES TO ANY OF #1-4, COMPLETE
YES/NO,N/A
COMMENTS:
ILSM
Date:
Initial:
1. Will egress routes/exits be affected?
2. Will fire protection system be affected?
(i.e. compartments, detectors, suppression systems)
3. Will the fire alarm system be affected?
4. Is access to emergency dept. affected?
5. Will hot work occur? (obtain permit from FM)
6. Will work involve large quantities of combustibles?
7. Will any fire/smoke barriers be penetrated?
2.
3.
CLASS IV
Additional Requirements: (If scope of project changes IPCE and ILSM needs to be notified)
Exceptions/Additions to this permit are noted by attached memoranda:
Permit Request By:
Title: Phone:
Date:
Date
Initials
ICRA Authorized By:
Date:
Title:
ILSM Authorized By:
Phone
Date:
Title:
Phone