Infection Control Risk Assessment

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Infection Control Risk Assessment (ICRA)
Facility / Site:
Project Start Date:
Job Name & Number:
Project End Date:
Location of Construction :
(Building, Department, Floor, Room)
Estimated Duration:
PROJECT SCOPE (Task Description)
DETERMINE CONSTRUCITON ACTIVITY TYPE (Circle One)
TYPE A – Inspection & Non-Invasive Activity
TYPE B – Create Minimal Dust on Small Scale, Short Duration Activities
Temporary lifting of ceiling tile for visual inspection with
Cut in wall or ceiling new device/fixture
immediate replace.
Replace ballast above ceiling
Replace ballast from below ceiling
Minor electrical work above ceilings using hand tools & not adding raceway
Replace existing trim/lamp on light fixture below ceiling
(i.e.) troubleshooting & repairs)
Replace surface mount ceiling devices
Pull cables using existing raceways (conduit, tray, J hooks)
Replace existing wall devices
Install surface mount raceway
Access to chase spaces
TYPE C – Moderate to High Level of Dust
TYPE D – High Level of Dust
Installing raceways above ceiling
Activity required more than 1 work shift
Work involving opening 2 or more consecutive ceiling tiles
Major demolition
Work involving through-wall penetrations
Major new construction
Work creating opening to interstitial area
DETERMINE PATIENT RISK GROUP (Circle One)
If more than one group will be affected, select the highest group.
Minimal Risk – Group 1
Low Risk – Group 2
Medium Risk – Group 3
High Risk – Group 4
(Non Patient Care)
(Outpatients – General Care)
(Inpatient Units)
(Immunocompromised Patients)
 Office areas not associated
Outpatient clinics
General care – Inpatient
Intensive Care
with patient care
areas
Patient care office areas
Operating rooms
 Electrical closets / rooms
including waiting areas
Emergency Room
Oncology
 Mechanical Rooms
Patient support areas
Surgical units
Cardiac cath labs
 Areas off limits to patients
Linen services
o
CCU
 Vacant areas next to Group 2
Burn unit
Kitchen
o
Endoscopy
Central sterile supply
o
Laboratory
Labor & Delivery
Anesthesia
Physical Therapy
Pharmacy
Hemodialysis
Radiology / MRI
Nursery
LTRU
Vacant areas next to Group 3
Vacant areas next to
Group 4
IC MATRIX – DETERMINE CLASS OF PRECAUTION USING IC MATRIX
Construction Project Type – Dust Level
Patient Risk Group
TYPE A
TYPE B
TYPE C
TYPE D
Minimal Risk Group 1
I
I
I
III
Low Risk Group 2
I
II
III
IV
Medium Risk Group 3
I
III
IV
IV
High Risk Group 4
II
III
IV
IV
Precaution Class:
 
ICRA Requested By: 
ICRA Approved By: 
Name (Print): 
 
Name (Print):   
Signature: 
 
Signature 
 
Date: 
 
Date: 
 
 
 

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