Form Cms-2786y - Fire Safety Evaluation System - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 4
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42012 Life Safety Code
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
Step 5 — Determine the Equivalency Evaluation using Worksheet 7.3.5.
(1) Perform subtractions indicated in Worksheet 7.3.5. Enter the differences in the appropriate answer blocks.
(2) For each row, check “yes” if the value in the answer block is zero (0) or greater. Check “no” if the value in
the answer block is a negative number.
WORKSHEET 7.3.5 EQUIVALENCY EVALUATION
Yes
No
S
S
1
a
Control
Required
>
Provided
minus
0
Control (S
)
-
=
a
(S
)
1
S
S
2
Egress
b
Required
>
Provided
minus
0
Egress (S
)
-
=
b
(S
)
2
S
S
3
c
Refuge
Required
>
Provided
minus
0
Refuge (S
)
-
=
c
(S
)
3
Required
S
S
d
General
4
General
>
Fire Safety
minus
0
Fire
-
=
(S
)
4
Safety (S
)
d
Step 6 — Evaluate Operating Features Requirements using Worksheet 7.3.6.
Complete one copy of this separate worksheet for each facility.
WORKSHEET 7.3.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET CONSIDERATIONS
NOT
MET
MET
Complies with the applicable requirements of Section 32.7 and 33.7 (NFPA 101).
Step 7 — Determine equivalency Conclusion to determine if the level of life safety is at least equivalent to that prescribed
by the Life Safety Code using Worksheet 7.3.7.
WORKSHEET 7.3.7 CONCLUSIONS
1.
All of the checks in Worksheet 7.3.5 are in the “Yes” column and all applicable considerations in
Worksheet 7.3.6 are identified as “Met”. The level of fire safety is at least equivalent to that prescribed by
NFPA 101, Life Safety Code, for small residential board and care occupancies.
2.
All of the checks in Worksheet 7.3.5 are in the “Yes” column and all considerations identified in
Worksheet 7.3.6 as “Not Met” have been evaluated and mitigated to the satisfaction of the AHJ. The
level of fire safety is at least equivalent to that prescribed by NFPA 101, Life Safety Code, for small
residential board and care occupancies.
3.
One or more of the checks in Worksheet 7.3.5 are in the “No” column or any consideration identified in
Worksheet 7.3.6 as “Not Met” has NOT been evaluated and mitigated to the satisfaction of the AHJ. The
level of fire safety is not shown by this system to be equivalent to that prescribed by NFPA 101, Life
Safety Code, for small residential board and care occupancies.
Form CMS-2786Y (10/2016)
Page 4
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