Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code Page 3
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7DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
Step 5 — Determine Safety Parameter Values using Worksheet 4.7.6.
(1) Select and circle the safety value for each safety parameter that best describes the conditions in the zone.
(2) Choose only one value for each of the 13 parameters.
(3) If two or more appear to apply, choose the one with the lowest point value.
WORKSHEET 4.7.6 – SAFETY PARAMETER VALUES
Safety Parameters
Parameters Values
1. Construction
Combustible
Non-Combustible
Types III, IV, and V
Types I and II
Floor or Zone
000
111
200
211, 2HH
000
111
222, 322, 442
First
-2
0
-2
0
0
2
2
Second
-7
-2
-4
-2
-2
2
4
Third
-9
-7
-9
-7
-7
2
4
4th and Above
-13
-7
-13
-7
-9
-7
4
2. Interior Finish
Class C
Class B
Class A
f
f
(Corridors and Exits)
-5(0)
0(3)
3
3. Interior Finish
Class C
Class B
Class A
f
f
(Rooms)
-3(1)
1(3)
3
≥1 hour
4. Corridor
None or Incomplete
<
1
/
hour
>
1
/
to <1 hour
2
2
a
a
a
Partitions/Walls
-10(0)
0
1(0)
2(0)
≥ 20 min FPR and
5. Doors to Corridor
≥ 20 min FPR
No Door
<20 min FPR
Auto Closure
d
d
-10
0
1(0)
2(0)
6. Zone Dimensions
Dead End
No Dead Ends >30 ft. and Zone Length Is
>100 ft.
>50 ft. to 100 ft.
30 ft. to 50 ft.
>150 ft.
100 ft. to 150 ft.
<100 ft.
b
b
b
c
h
h
-6(0)
-4(0)
-2(0)
0(0)
1
-2(0)
(0)
7. Vertical Openings
Open 4 or More
Open 2 or 3
Enclosed with Indicated Fire Resistance
≥1 hr. to <2 hr.
≥2 hr.
Floors
Floors
<1 hr.
e
e
-14
-10
0
2(0)
3(0)
8. Hazardous Areas
Double Deficiency
Single Deficiency
No Deficiencies
In Zone
Outside Zone
In Zone
In Adjacent Zone
-11
-5
-6
-2
0
9. Smoke Control
No Control
Smoke Barrier
Mechanically Assisted Systems
Serves Zone
by Zone
c
-5(0)
0
3
10. Emergency
<2 Routes
Multiple Routes
Direct Exit(s)
Movement
W/O Horizontal
Horizontal
Deficient
Routes
Exit(s)
Exit(s)
-8
-2
0
1
5
11.Manual Fire Alarm
Manual Fire Alarm
No Manual Fire Alarm
W/O F.D. Conn.
W/F.D. Conn.
1
2
-4
12. Smoke Detection
Corridor and
Total Spaces
None
Corridor Only
Rooms Only
and Alarm
Habit. Spaces
in Zone
g
g
g
0(3)
2(3)
3(3)
4
5
Corridor and
Entire
13. Automatic
None
Habit. Space
Building
Sprinklers
0
8
10
a
f
Use (0) where parameter 5 is -10.
Use ( ) if the area of Class B or C interior finish in the corridor and exit or room is
b
protected by automatic sprinklers and Parameter 13 is 0; use ( ) if the room with
Use (0) where parameter 10 is -8.
existing Class C interior finish is protected by automatic
sprinklers, Parameter 4 is
c
Use (0) on floor with fewer than 31
greater than or equal to 1, and Parameter 13 is 0.
patients (existing buildings only).
g
Use this value in addition to Parameter 13 if the entire zone is protected with quick-
d
Use (0) where parameter 4 is -10.
response automatic sprinklers.
e
Use (0) where Parameter 1 is based on first floor zone
h
Use (0) where zone area ≤ 22,500 ft.
2
and distance from any point to
or on an unprotected type of construction (columns
reach a door in smoke barrier is ≤ 200 ft.
marked “000” or “200”).
For SI Units: 1 ft.² = 0.3048 m²
Form
CMS-2786T (10/2016)
Page
3
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