Risk Criteria Yes No Comments

1. Will the construction directly affect patient

care areas?

2. Does the construction area contain any

environmental hazards?
Asbestos
Chemicals
Others

3. Air Quality
A. Has the location of the outside air
intakes been taken into consideration?

B. Will the HVAC system need to be

rebalanced prior to construction to ensure
propser air flow requirements?

4. Are Utility Shut Downs Required (check

below)
Fire Detection System
Sprinkler
Electric
HVAC
Hot / Cold Domestic Water
Sanitary
Steam
Other ___________________________

5. Will construction activities create enough

noise to be disruptive?

6. Will construction activies cause enough

vibration to be disruptive?

7.
Will contractor deliveries or debris removal
be made outside of normal working hours?
8.

Will debris removal require more than

standard precautions (removal in covered
carts wiped down with disinfectant)?
 Pre-Construction Risk Assessment (PCRA)
Project Name: Project Location:
FDC# Project Manager:
Architect: Contractor:
Project Description:

See page 2 for additional information, interventions or action plans

YES NO
A. Will construction directly affect patient care areas?
Spaces adjacent to, above and below the construction area must be considered.
B. Will HVAC systems be affected by the construction (i.e., outside air intakes, exhaust
systems, air handlers)? If yes, note which systems and provide an action plan.
C. Are Utility Shut Downs Required? Check all that apply.
HVAC Steam
Hot / Cold Domestic Water Medical Gas
Sanitary Electric
Other (Specify):
ALL utility shut downs must be coordinated with contractor, Facilities Services, affected departments
and hospital administration in order to minimize disruption to operations.
D. Will construction activities generate noise that will disrupt occupants adjacent to,
above, or below the construction area?
a. If yes, affected occupants must be notified.
b. How will work be managed to minimize disruption?

E. Will construction activities generate vibration that will disrupt occupants adjacent to,
above, or below the construction area?
a. If yes, affected occupants must be notified.
b. How will work be managed to minimize disruption?

F. Does the construction area contain any environmental hazards?

Asbestos Chemicals (Specify):
Other (Specify):

G. Will contractor deliveries or debris removal be made outside of normal working hours?
If yes, describe hours and any special requirements.

H. Will debris removal require precautions above and beyond those required for the
assigned ICRA precaution level? (i.e., covered carts, wiped down for levels III-IV)
If yes, describe additional precautions.

I. Are there any other circumstances that may affect care, treatment and services?

YES NO
Has an ICRA been developed for this project?
Date Reviewed _______________________ ICRA Level Assigned _________________

Reviewed by: Date:

TJC Standard EC 02.06.05 states that space must be managed during demolition, renovation or new construction to reduce risk to
those in the organization. This form addresses Element of Performance 2. An ILSM must be completed to comply with Element of
Performance 3 (See ILSM for Construction and Renovation Projects Form). An ICRA must be completed to comply with Element of
Performance 3 (See Infection Control Risk Assessment and Permit Form).
Page 2 Pre-Construction Risk Assessment (PCRA)
ADDITIONAL INFORMATION

Project Name: Project Location:

FDC# Project Manager:
Architect: Contractor:

YES NO
A. Spaces that will be affected:

B. HVAC systems affected by the construction:

C. Utility Shutdowns with greater than usual impact:

D. Construction activities generating disruptive noise:

E. Construction activities generating disruptive vibration:

F. Environmental hazards requiring special attention:

G. Deliveries or debris removal made outside of normal working hours:

H. Debris removal require precautions above and beyond those required for the
assigned ICRA precaution level?

I. Are there any other circumstances that may affect care, treatment and services?

Reviewed by :
Initials
Kriteria Resiko Ya Tidak Komentar
1.
Akankah konstruksi langsung
mempengaruhi area perawatan pasien?

2. Apakah area konstruksi mengandung

bahaya lingkungan?
Asbes
Bahan kimia
Lainnya

3. Kualitas Udara
A. Apakah lokasi pemasukan udara luar
telah dipertimbangkan?

B. Akankah sistem HVAC perlu

diseimbangkan kembali sebelum konstruksi
untuk memastikan persyaratan aliran udara
alat peraga?

4.
Apakah sistem utilitas perlu dimatikan?
Sistem deteksi kebakaran
Sprinkler
Listrik
HVAC
Air Panas/Dingin
Sanitasi
Uap
Other ___________________________

5.
Apakah pekerjaan konstruksi menciptakan
kebisingan yang cukup mengganggu?

6.
Apakah pekerjaan konstruksi menyebabkan
getaran yang cukup mengganggu?

7.
Apakah pengiriman kontraktor atau
pembersihan puing dilakukan diluar jam
kerja?
8.
apakah pengangkutan dan pemindahan
puing dilakukan menggunakan gerobak
tertutup?
 Pre-Construction Risk Assessment
Nama Proyek: Lokasi Proyek :
FDC# Manajer Proyek :
Arsitek : Kontraktor :
Deskripsi Proyek

Lihat halaman 2 untuk informasi tambahan, intervensi atau rencana aksi

Ya Tidak
A. Apakah konstruksi akan mempengaruhi area perawatan pasien secara langsung?
Ruang yang berdekatan dengan, diatas dan dibawah area konstruksi harus dipertimbangkan
B. Apakah pekerjaan konstruksi akan berdampak pada sistem HVAC? (udara luar, sistem
exhaust, sistem penanganan udara). Jika ya, tulis sistem mana dan berikan rencana tinda
C. Apakah sistem Utilitas perlu dimatikan? Periksa semua yang berlaku
HVAC
Air panas/dingin
Sanitasi
Lainnya (tentukan)

Semua sistem utilitas yang dimatikan harus dikoordinasikan dengan kontraktor, bagian fasilitas ru
sakit, instalasi/ruangan yang terkena dampak dan administrasi rumah sakit untuk meminimalkan
D. Akankah kegiatan konstruksi menghasilkan kebisingan yang akan mengganggu
penghuni yang berdekatan dengan area konstruksi?
a. Jika Ya, penghuni yang terkena dampak harus diberi tahu
b. Bagaimana cara kerja dikelola untuk meminimalisir gangguan?

E. Akankah kegiatan konstruksi menghasilkan getaran yang akan mengganggu

penghuni yang berdekatan dengan area konstruksi?
a. Jika Ya, penghuni yang terkena dampak harus diberi tahu
b. Bagaimana cara kerja dikelola untuk meminimalisir gangguan?

F. Apakah area konstruksi mengandung bahaya lingkungan?

Asbes Bahaya Kimia (Spesifikasikan)
Lainnya (tentukan)

G. Apakah pengiriman kontraktor atau pembersihan puing dilakukan diluar jam kerja normal?
Jika Ya, jelaskan jam dan persyaratan khusus apapun

H. Will debris removal require precautions above and beyond those required for the
assigned ICRA precaution level? (i.e., covered carts, wiped down for levels III-IV)
If yes, describe additional precautions.
 I. Are there any other circumstances that may affect care, treatment and services?

YES NO
Has an ICRA been developed for this project?
Date Reviewed _______________________ ICRA Level Assigned ________________

Reviewed by:

TJC Standard EC 02.06.05 states that space must be managed during demolition, renovation or new construction to reduce risk
in the organization. This form addresses Element of Performance 2. An ILSM must be completed to comply with Element of Pe
3 (See ILSM for Construction and Renovation Projects Form). An ICRA must be completed to comply with Element of Performan
Infection Control Risk Assessment and Permit Form).

Page 2 Pre-Construction Risk Assessment

Project Name: Project Location:

FDC# Project Manager:
Architect: Contractor:

YES NO
A. Spaces that will be affected:

B. HVAC systems affected by the construction:

C. Utility Shutdowns with greater than usual impact:

D. Construction activities generating disruptive noise:

E. Construction activities generating disruptive vibration:

 F. Environmental hazards requiring special attention:

G. Deliveries or debris removal made outside of normal working hours:

H. Debris removal require precautions above and beyond those required for the
assigned ICRA precaution level?

I. Are there any other circumstances that may affect care, treatment and services?

Reviewed by :
Initials
onstruction Risk Assessment (PCRA)

vensi atau rencana aksi

atan pasien secara langsung?

h area konstruksi harus dipertimbangkan
sistem HVAC? (udara luar, sistem
stem mana dan berikan rencana tindakan
mua yang berlaku
Uap
Gas Medis
Listrik

ikan dengan kontraktor, bagian fasilitas rumah

nistrasi rumah sakit untuk meminimalkan gangguan
gan yang akan mengganggu

sir gangguan?

yang akan mengganggu

sir gangguan?

Bahaya Kimia (Spesifikasikan)

uing dilakukan diluar jam kerja normal?

beyond those required for the

, wiped down for levels III-IV)
 are, treatment and services?

RA Level Assigned _________________

Date:

enovation or new construction to reduce risk to those

be completed to comply with Element of Performance
mpleted to comply with Element of Performance 3 (See

onstruction Risk Assessment (PCRA)

ADDITIONAL INFORMATION

Location:
Manager:
l working hours:

nd those required for the

are, treatment and services?