Form Cms-2786y - Fire Safety Evaluation System - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 3
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42012 Life Safety Code
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
Step 3 — Complete Individual Safety Evaluations using Worksheet 7.3.3.
(1) Transfer each of the eight circled safety parameter values from Worksheet 7.3.2 to every available block in
the line with the corresponding safety parameter in Worksheet 7.3.3. Where the block is marked “÷ 2 =,” enter
one-half the value from Worksheet 7.3.2.
(2) Add each of the four columns, keeping in mind that any negative numbers need to be deducted.
(3) Transfer the resulting values for S1, S2, S3, and S4 to the corresponding blocks in Worksheet 7.3.5.
WORKSHEET 7.3.3 INDIVIDUAL SAFETY EVALUATIONS
General Fire
Fire Control (S
)
Egress (S
)
Refuge (S
)
Safety Parameters
1
2
3
Safety (S
)
4
1. Construction
2. Hazardous Areas
– : 2 =
– : 2 =
(See note)
3. Manual Fire Alarm
4. Smoke Detection and Alarm
– : 2 =
– : 2 =
– : 2 =
5. Automatic Sprinklers
– : 2 =
6. Interior Finish
7. Separation of
Sleeping Rooms
8. Means of Escape
S 1 =
S 2 =
S 3 =
S 4 =
Total
NOTE: Maximum value of manual fire alarm for means of escape is 1.
Step 4 — Determine Mandatory Safety Requirements using Worksheet 7.3.4A or 7.3.4B, as appropriate.
(1) Select the level of requirements from Worksheet 7.3.4A or 7.3.4B as appropriate. Circle the appropriate
values.
(2) Transfer the circled values from Worksheet 7.3.4A or 7.3.4B to the corresponding blocks for Sa, Sb, Sc, and
Sd in Worksheet 7.3.5.
WORKSHEET 7.3.4A MANDATORY SAFETY REQUIREMENTS – NEW FACILITIES
Control
Egress
Refuge
General Fire Safety
Requirement
Requirement
Requirement
Requirement
(S
)
(S
)
(S
)
(S
)
a
b
c
d
10.5
5
11.5
7
WORKSHEET 7.3.4B MANDATORY SAFETY REQUIREMENTS – EXISTING FACILITIES
Level of Evacuation
Control
Egress Requirement
Refuge Requirement
General Fire Safety
Difficulty
Requirement (S a )
(S b )
(S c )
Requirement (S d )
Prompt
0
4
2
1
Slow
2
7
4
7
Slow *
1
6
2
5
Impractical
8
9
9
10
* Use these mandatory safety requirements if the evacuation capability score is 3 or less as determined by Chapter 6, NFPA 101A.
Form CMS-2786Y (10/2016)
Page 3
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