Form Cms-2786y - Fire Safety Evaluation System - Icf-Iid (Small Facilities) 2012 Life Safety Code
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42012 Life Safety Code
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
FIRE SAFETY EVALUATION SYSTEM
Intermediate Care Facilities for Individuals with Intellectual Disabilities
SMALL FACILITIES
(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)
Complete these worksheets for each individual resident or apartment used as a small residential board and care facility*.
* A small residential board and care facility with a capacity of 16 or fewer residents.
Step 1 — Complete Cover Sheet using Worksheet 7.3.1.
WORKSHEET 7.3.1 – COVER SHEET
ZONE
OF
ZONES
FACILITY NAME
ADDRESS OF FACILITY
ZONE(S) EVALUATED
PROVIDER/VENDOR NO.
DATE OF SURVEY
SURVEYOR SIGNATURE
DATE
TITLE
OFFICE
SURVEYOR ID
FIRE AUTHORITY SIGNATURE
TITLE
OFFICE
DATE
ADDITIONAL COMMENTS:
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Form CMS-2786Y (10/2016)
Page 1
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