Free Ceiling Closure Inspection Checklist-F-00014 - Wisconsin


File Size: 22.1 kB
Pages: 2
Date: December 19, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 765 Words, 4,857 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms/f0/f00014.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-00014 (12/08)

STATE OF WISCONSIN Page 1 of 2

CEILING CLOSURE INSPECTION CHECKLIST
Name - Facility Project Distribution To Name ­ DHS Inspector Area Inspected Tour With DHS Inspector No. Inspection Date Anticipated Occupancy Date

Item EXAMPLE: Adjacent Spaces

ID A

Inspection Spot Check Method and Code (NFPA 101, unless otherwise shown) (1) Dust free; (2) Sep contr path; (3) Clean mat; (4) Exit path; (5) Sprkled [§4.6.10.1]

No.

ID + No. C­2

Issue Locations Exit blocked by pipes

Risk Management
Adjacent Spaces Barriers Pathway Neg Ventilation Protective Equipment Debris Electrical A B C D E F G (1) Dust free; (2) Sep contr path; (3) Clean mat; (4) Exit path (1) Rated, if no sprkler/smk detect/fire watch; (2) Dust tight to pt spaces (1) Interior mats; (2) Clear paths [§4.6.10.2]; (3) Exits marked (1) Neg fan if adj to pt areas; (2) Recorded pressure > .02":wg (1) Hard hats, if work overhead; (2) Follow hosp PPE rules (1) Trash ­ excess removed; (2) Dust clean [241 §3-4.1] (1) No open power

Fire Proof
Attachment ­ Small Attachment ­ Large Wall Track Wall Channel Fireproof ­ Missing Utility Infringe H I J K L M (1) Beam clamps, small attachments [220 §3] (1) Large attachments [220 §3] (1) Top track tight to steel [220 §3] (1) Hat channel tight to steel [220 §3] (1) Missing insulation; (2) Thin insulation [220 §3] (1) Piping next to steel; (2) Duct next to steel [220 §3]

Building Construction
Wall Construction Penetration ­ Wall Penetration ­ Floor Won/Vert Door Demo N O P Q R (1) Rated walls taped on both sides/screws mudded; (2) Top seal; (3) No parallel ducts/pipes (1) Qual seals per UL design [§8.2.3.2.4.2] (1) In-wall cavities per UL design quality [§8.2.3.2.4.2] (1) 2-hr framed supports (1) Abandoned utilities removed

Exits
Egress Path Exit Signs Exits Corridors Suite S T U V W (1) To public way [§7.71]; (2) Multi lamp/fixt [§77.8.1.4]; (3) No haz [§7.5.1.7]; (4) Min 3' [§7.3.4.1] (1) Path not apparent [§7.10.1.4]; (2) No exit if may be mistaken [§7.10.8.1]; (3) Stair sign [§7.10.1.3] (1) No pass-thru util [§7.1.3.2.1] (1) Open rms w/smk det [§18.3.6.1]; (2) Dead end < 20'; (3) InPt = 8'; (4) Other = 4' [§18.2.3.3] (1)<100' TD w/1 rm; (2)<50' w/2 rms; (3)<5 ksf-sleep; (4)<10 ksf-other; (5) 2 exits>2.5 ksf [§18.2.5.1]

F-00014 (12/08)

Page 2 of 2

Doors
Fire Barrier Doors Smoke Barrier Door Corridor Doors Dutch (in corr) X Y Z AA (1) Self-close; (2) Latch; (3) Hold open w/smk det; (4) Rated; (5) 1/8" gap; (6) 30# open [§8.2.3.2] (1) Self-close; (2) Astragal; (3) Hold open w/smk det; (4) Dual egress; (5) 1 ¾" / 20m [§18.3.7.5-8] (1) Latch [§18.3.6.3], double drs; (2) Astragal; (3) Auto-flush [§18.2.3.5], out-swing; (4) >50%; (5) >7" [§7.2.1.4.4] (1) Self-latch; (2) Sealed gap [§18.3.6.3.6]

Sprinkler
Fire Extinguisher Sprinkler Block Spacing Valves BB CC DD EE (1) Conspicuous; (2) Accessible; (3) Tagged; (4) < 150' apart [§7.9.4 ­ NFPA 10] (1) Ceiling blockage; (2) Shelf blockage; (3) Wall shadow [13 §6-5]; (4) Open ceiling (1) No spklr; (2) > 6'; (3) < 15' apart; (4) > 4" corners; (5) > 7 ½ ` to wall; (6) 12" to ceiling [13 §5-6.3] (1) Valves supervise; (2) QR in sleep smk comp [§18.3.5]

Fire Alarm
Fire Alarm Op Smoke Detectors Staff Training FF GG HH (1) Doors close; (2) Strobes visible; (3) Audible volume [§18.3.4] (1) > 3' to air grills; (2) @ door holds; (3) 2 @ 24" hdr [72 §2-10.6] (1) Staff know how to respond; (2) Staff know compartments [§18.7.2]

Med Gas
Piping Valve, Isolation Zone Valve and Alarm II JJ KK (1) Labeled with gas and (2) flow direction [99 §4-3.1.2.14] (1) Labeled; (2) Locked [99 §4-3.1.2.3] (1) Labeled with gas and (2) space served; (3) Close-caution sign [99 §4-3.1.2.14]

Ventilation
Fire Dampers Smoke Dampers Duct Smoke Detectors LL MM NN (1) At 2 hr walls/shafts [90A §3-3.1]; (2) Mfgr install [§3-4.6]; (3) Access door; (4) Label [§2-3.4] (1) Iso AHU > 15 kcfm on SA and (2) RA [90A §2-3.9.2]; (3) RA into riser [IBC] (1) AHU > 2 kcfm: SA main prior to branch; (2) AHU > 15 kcfm: RA @ shafts and (3) AHU [§4-4.2]

Specialty Areas
Kitchen Hoods Anesthetizing Loc Life Support ­ Med Gas OO PP QQ (1) UL300 sys; (2) FA connect; (3) w/utility shut-down; (4) K exiting [96 §7]; (5) Hood MU air [96 §5-3] (1) Med gas valves; (2) Alarm [99 §4-3.1.2.2&3]; (3) Smoke vent sys seq of op [99 §5-4] (1) Med gas valves; (2) Alarm [99 §4-3.1.2.2&3]

Misc
RR SS TT UU VV WW It is acceptable to close ceiling, provided (1) the local AHJ gives approval, (2) all issues are corrected, and (3) certification of correction is e-mailed to the state inspector. The construction manager must submit photographic evidence of correction of items marked with a "P." Reinspection is required. Please call to schedule. SIGNATURE - Inspector Date Signed