Form Osh-Fd-125 Post Approval Document Page 3
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4OFFICE OF STATEWIDE HEALTH PLANNING AND DEVELOPMENT
FACILITIES DEVELOPMENT DIVISION
INSTRUCTIONS FOR POST APPROVAL DOCUMENT
(OSH-FD-125)
If this is a Deferred Item this form must be accompanied by a Project Information form OSH-FD-100.
Note: If licensure by the California Department of Public Health is not required by your facility, review by OSHPD is not
required; therefore this application is not required. Contact the local jurisdiction for submittal requirements.
Facility
• Enter the Office of Statewide Health Planning and Development (OSHPD) project number.
• Enter the OSHPD facility identification number.
• Enter the name of the facility as it appears on the facility license.
• Enter the OSHPD building number and building name where the work is to be performed.
• Indicate the type of facility as it is licensed.
Record Detail
• Enter the record/project name.
• Enter a detailed description of the work to be performed.
Application Specific Information – Post Approval Document
Note: A non-refundable application fee of $250.00 will be assessed for each Post Approval Document Submittal.
Indicate if the Post Approval Document submittal is for an Amended Construction Document or a Deferred Item. If this is a
Deferred Item this form must be accompanied by a Project Information form OSH-FD-100.
• Provide an applicant tracking number, if applicable.
• Provide a reason this change is being requested.
• Provide the scope of the change being requested.
• Provide the signature of the architect or engineer in responsible charge of the project, and date. If this application is for
a project that includes primary gravity and/or lateral load elements/systems, provide the signature of the Structural
Engineer, and date.
Application Specific Information – Critical Path Expedite Review
• Indicate if requesting a Critical Path Expedite Review (CPER).
• Provide justification for this request, if applicable.
Costs
• Select whether the costs indicated are estimated or contract.
• Enter the amount of change in the construction cost of the project excluding fixed equipment to be permanently
attached (electrically, mechanically or structurally) to the building, imaging equipment, design fees, inspection fees, and
off-site improvements. For SB 1838 projects, this amount must not exceed $50,000.
• Enter the amount of change in the cost or value of fixed equipment (items that are permanently affixed to the building or
permanently connected to a service distribution system that is designed and installed for the specific use of the
equipment), excluding installation costs.
• Enter the amount of change in cost or value of imaging equipment (X-ray, MRI, CT Scan, etc.), excluding installation
cost.
Enclosures
• Indicate the number of copies enclosed in the space provided, next to the applicable enclosure type.
• List all drawing sheets included with this submittal.
STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
OSH-FD-125 (Rev 11/11/11)
Instruction Page 1 of 2
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