Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code
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72012 LIFE SAFETY CODE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
FIRE SAFETY EVALUATION SYSTEM
HEALTH CARE FACILITIES
(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)
Complete the following worksheets for each fire/smoke zone*.
Where conditions are the same in several zones, one set of worksheets can be used for those zones.
* Fire/smoke zone is a space separated from all other spaces by floors, horizontal exits, or smoke barriers
Step 1 — Complete Cover Sheet using Worksheet 4.7.1.
WORKSHEET 4.7.1 – COVER SHEET
ZONE
OF
ZONES
NAME OF FACILITY
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-2786T (10/2016)
Page
1
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