INFECTION CONTROL CONSTRUCTION CONSULTATION FORM NUMBER 2

Project #:

Job #:

Control No:

Project Area:

Project Start Date:

Project Coordinator:

Estimated Completion Date:

General Contractor:

Pager #:

OSHPD Permit #:

Contractor Superintendent:

Superintendent Telephone #:

YES

NO

CONSTRUCTION ACTIVITY

YES

NO

INFECTION CONTROL RISK GROUP

TYPE A: Inspection, non-invasive activity.

GROUP 1: Lowest Risk

TYPE B: Small scale; short duration, minimal dust generating activity.

GROUP 2: Medium Risk

TYPE C: Activity that generates moderate to high levels of dust, requires greater that one week for completion.

GROUP 3: Medium/High Risk

TYPE D: Major duration and construction activities requiring consecutive work shifts.

GROUP 4: High Risk

RISK GROUP

CONSTRUCTION ACTIVITY

TYPE A

TYPE B

TYPE C

TYPE D

GROUP 1 Low Risk

CLASS I

CLASS II

CLASS II

CLASS III or CLASS IV

GROUP 2 Medium Risk

CLASS I

CLASS II

CLASS III

CLASS IV

GROUP 3 Medium High Risk

CLASS I

CLASS II

CLASS III or CLASS IV

CLASS IV

GROUP 4 High Risk

CLASS II

CLASS III or CLASS IV

CLASS III or CLASS IV

CLASS IV

CLASS I DATE: INITIALS:

a. Must obtain infection control consult before construction begins. b. Signage will be required and posted at the facility by the Infection Control Officer or their designee.

c. Execute work by methods to minimize raising dust from construction operation. d. Immediately replace a ceiling tile displaced for visual inspection.

CLASS II DATE: INITIALS:

a. Must obtain infection control consult before construction begins. b. Signage will be required and posted at the facility by the Infection Control Officer or their designee. c. Isolate HVAC system in areas where work is being performed. d. Block and seal air vents. e. Provide active means to prevent airborne dust from dispersing into atmosphere. f. Water mist or wet work surfaces to control dust while cutting. g. Seal unused doors with duct tape h. Place/replace dust mat at entrance and exit of work area daily.

i. Contractor will wet mop areas with hospital approved disinfectant daily. j. Environmental Services will wipe all surfaces within immediate patient care environment and staff areas with a hospital approved disinfectant daily. k. Contain construction waste before transport in tightly covered containers. l. Contractor shall vacuum with HEPA filtered vacuum before leaving area daily. m. Provide monitoring of air quality immediately before, during and immediately after work utilizing methods and equipment specified.

CLASS III DATE: INITIALS:

a. Must obtain infection control consult before construction begins. b. Signage shall be required and posted at the facility by the Infection Control Coordinator or their designee. c. Remove or isolate HVAC system in areas where work is being done to prevent contamination of duct system. d. Complete construction of all critical barriers before construction begins. (see specifications) e. Maintain negative air pressure within work site utilizing HEPA air filtration units. f. Do not remove barriers from work area until complete project is thoroughly cleaned. g. Vacuum work area with HEPA filtered vacuum. h. Remove barrier material carefully folding inward to minimize the

spread of dirt and debris. i. Vacuum all surfaces with HEPA filtered vacuum to remove dust. j. Contain construction waste before transport in tightly covered containers. k. Cover transport receptacles or carts. l. Tape covering unless receptacle has a solid lid. m. Contractor shall wet mop areas with hospital approved disinfectant daily. n. Environmental Services will wipe all surfaces within immediate patient care environment and staff areas with a hospital approved disinfectant daily. o. Provide monitoring of air quality immediately before, during and immediately after work utilizing methods and equipment specified.

CLASS IV DATE: INITIALS:

a. Must obtain infection control consult before construction begins. b. Signage shall be required and posted at the facility by the Infection Control Coordinator or their designee. c. Remove or isolate HVAC system in areas where work is being done to prevent contamination of duct system. a. Complete construction of all critical barriers before construction begins. (see specifications) b. Maintain negative air pressure within work site utilizing HEPA air filtration units. c. Seal holes, pipes, conduits and punctures with duct tape or other material. d. Construct anteroom where feasible and require all personnel to pass through this room cleaning equipment and clothing using HEPA vacuum before leaving or entering the work site or they can wear cloth or paper coveralls that are removed each time they leave the work site. e. All personnel entering the work site are required to wear shoe covers. Shoe covers must be changed each time the worker exits the work site.

f. Do not remove barriers from work area until complete project is thoroughly cleaned. g. Vacuum work area with HEPA filtered vacuum. h. Remove barrier material carefully folding inward to minimize spreading of dirt and debris. i. Vacuum all surfaces with HEPA filtered vacuum to remove dust. j. Contain construction waste before transport in tightly covered containers. k. Cover transport receptacles or carts. Tape covering unless receptacle has a solid lid. l. Contractor shall wet mop areas with hospital approved disinfectant daily. Any dust tracked outside the area shall be removed immediately. m. Environmental Services will wipe all surfaces within immediate patient care environment and staff areas with a hospital approved disinfectant daily. n. Provide monitoring of air quality immediately before, during and immediately after work utilizing methods and equipment specified.

Additional Requirements:

Contractor: (print)

Sign:

Date:

Project Manager: (print)

Sign:

Date:

Infection Control Coordinator: (print)

Sign:

Date: