INFECTION CONTROL CONSTRUCTION CONSULTATION
FORM NUMBER 1
DATE__________________
BUILDING_________________FLOOR _____________AREA__________________
START
DATE____________________________SHIFT__________________________
ESTIMATED COMPLETION
DATE__________________________________________
CONSTRUCTION
HOURS__________________________________________________
PURPOSE OF CONSTRUCTION
___________________________________________
_______________________________________________________________________
SUMMARY OF CONSTRUCTION TO
BE PERFORMED__________________________
_______________________________________________________________________
SPECIAL HAZARD
(S)_____________________________________________________
_______________________________________________________________________
POSSIBLE
INCONVENIENCES_____________________________________________
_______________________________________________________________________
HANDLING OF CONSTRUCTION
DEBRIS____________________________________
_______________________________________________________________________
INSTALLATION OF CONSTRUCTION
BARRIER/S OR WALL/S? ___________________
MECHANICAL DEVICE(S) TO
PREVENT OR LIMIT EXPOSURE___________________
SECURING AIR DISTRIBUTION
SYSTEM?____________________________________
SPECIAL PROCEDURES
__________________________________________________
_______________________________________________________________________
CONTRACTOR_______________________________________PHONE______________
SUPERINTENDENT___________________________________PHONE______________
INFECTION
CONTROL COORDINATOR___________________PHONE______________
PROJECT
MANAGER__________________________________PHONE______________