Free Health Care Facility Construction Documentation Checklist-F-62494 - Wisconsin



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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62494 (Rev. 01/09) STATE OF WISCONSIN Page 1 of 2 HEALTH CARE FACILITY CONSTRUCTION DOCUMENTATION CHECKLIST This form is a reference tool for the industry and for Department of Health Services (DHS) health care facilities construction inspectors. This form is intended to assist in the preparation of the Project Occupancy Inspection. Completion of appropriate requirements is necessary for final occupancy. Contact the reviewing DHS Health Care Facility Engineer for your project with questions. Office Central Office Northern Regional Office Northeastern Regional Office Southeastern Regional Office Southern Regional Office Western Regional Office Name - Facility Location Madison Rhinelander Green Bay Milwaukee Madison Eau Claire Telephone 608-264-7748 715-365-2800 920-448-5240 414-2

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62494 (Rev. 01/09)

STATE OF WISCONSIN Page 1 of 2

HEALTH CARE FACILITY CONSTRUCTION DOCUMENTATION CHECKLIST
This form is a reference tool for the industry and for Department of Health Services (DHS) health care facilities construction inspectors. This form is intended to assist in the preparation of the Project Occupancy Inspection. Completion of appropriate requirements is necessary for final occupancy. Contact the reviewing DHS Health Care Facility Engineer for your project with questions. Office Central Office Northern Regional Office Northeastern Regional Office Southeastern Regional Office Southern Regional Office Western Regional Office
Name - Facility

Location Madison Rhinelander Green Bay Milwaukee Madison Eau Claire

Telephone 608-264-7748 715-365-2800 920-448-5240 414-227-5000 608-266-7474 715-836-4752

FAX 608-267-0352 715-365-2815 920-448-5254 414-227-4139 608-266-8975 715-836-2535

Address (Street Address)

City

State

Zip Code

Facility Type

ASC
Project Description

CBRF

ESRD

Hospice

Hospital

Nursing Home

Other

Documentation Requirements 1. 2. 3. 4. 5. 6. 7. 8. 9.
Department of Commerce plumbing inspection report LOCAL building inspection approval or copy of occupancy permit Written statement from the local zoning authority that the proposed use of the building is not in conflict with zoning regulations Sprinkler system report (NFPA 13 Form) Documentation that sprinkler system is electrically supervised (NFPA 101) Local or state electrical inspection report Documentation by installer that the emergency generator has been tested and functioning properly and a list of areas or systems covered by the emergency power system (NFPA 70 & 99) Local fire inspection report CBRF fire protection installation report (NFPA 72) Fire and smoke damper documentation of locations Provide documentation by installer that fire alarm has been tested, including all devices electrically interconnected, and is fully operative as designed and approved (Use NFPA 72 form.) (required for NEW hospitals, nursing homes, and ASCs)

Yes

No

N/A

Comments

10. (NFPA 90A)

11.

F-62494 (Rev. 01/09)

Page 2 of 2

Documentation Requirements 12. accordance with NFPA 72
Documentation that fire alarm system is installed in

Yes

No

N/A

Comments

13. Fire Fighting Equipment Placement/Operating Tag
System Documentation that all smoke/heat detectors, sprinkler flow alarms, smoke dampers, and smoke control devices have been installed correctly and tested in conformance to respective codes; are interconnected and operate with the fire alarm system, as designed and approved Provide documentation of electrical performance criteria

14.

15. and testing per NFPA 99, Chapter 3 and 7.

16. Medical gas systems report (NFPA 99 Form) 17. Nurse call system documentation 18. HVAC Final Balance Report (COMM. 64.0313) 19. Interior finishes, i.e., wall, ceilings, floor, etc. 20. Flame spread documentation 21. Carpet installation certification 22. Cubicle curtain/drape fire retardant documentation 23. Elevator certification 24. Safe access to public way provided 25. Grab bar placement 26. Compliance Statement (F-62495) 27. Total number of beds in use 28. Number of beds licensed or certified
The items below are for nursing homes and sub-acute ONLY. The following data needs to be submitted by the licensee with the application form for license to operate a nursing home:

29. Exterior photograph taken from front street 30. assigned room numbers
Floor plan showing patient room sizes, as built, and facility

Comments and Miscellaneous Information

File Size: 22.9 kB
Pages: 2
Date: December 17, 2008
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 540 Words, 3,637 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/F6/F62494.pdf