Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code Page 4
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7DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
Step 6 —
Compute Individual Safety Evaluations using Worksheet 4.7.7.
(1) Transfer each of the 13 circled Safety Parameter Values from Worksheet 4.7.6 to every unshaded block in
the line with the corresponding Safety Parameter in Worksheet 4.7.7. For Safety Parameter 13 (Sprinklers)
the value entered in the People Movement Safety column is recorded in Worksheet 4.7.7 as 1/2 the
corresponding value circled in Worksheet 4.7.6.
(2) Add the four columns, keeping in mind that any negative numbers deduct.
(3)
Transfer the resulting total values for S1, S2, S3, S4 to blocks labeled S1, S2, S3, S4 in Worksheet 4.7.9 on
page 4 of this sheet.
WORKSHEET 4.7.7 - INDIVIDUAL SAFETY EVALUATIONS
Safety Parameters
Containment
Extinguishment
People
General
Safety
(S
)
Movement
2
Safety
(S
)
Safety (S
)
1
4
Safety (S
)
3
Construction
1.
Interior Finish (Corr. and Exit)
2.
Interior Finish (Rooms)
3.
Corridor Partitions and Walls
4.
Doors to Corridor
5.
Zone Dimensions
6.
Vertical Openings
7.
Hazardous Areas
8.
Smoke Control
9.
Emergency Movement Routes
10.
Manual Fire Alarm
11.
Smoke Detection and Alarm
12.
Automatic Sprinklers
÷ 2 =
13.
Total Value
S
=
S
=
S
=
S
=
1
2
3
4
Form
CMS-2786T (10/2016)
Page
4
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