Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code (Page 7 of 7) in pdf

Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code Page 7

DEPARTMENT OF HEALTH AND HUMAN SERVICES

2012 LIFE SAFETY CODE

CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB Exempt

Step 10 — Determine the equivalency Conclusion to determine if the level of life safety is at least equivalent to that

prescribed by the Life Safety Code using Worksheet 4.7.11.

WORKSHEET 4.7.11- CONCLUSIONS

All of the checks in Worksheet 4.7.9 are in the “Yes” column and all applicable considerations in Worksheet

4.7.10 are marked as “Met”. The level of safety is at least equivalent to that prescribed by NFPA 101, Life

Safety Code, for health care occupancies.

All of the checks in Worksheet 4.7.9 are in the “Yes” column and all considerations in Worksheet 4.7.10

marked as “Not Met” have been evaluated and mitigated to the satisfaction of the AHJ. The level of safety is

at least equivalent to that prescribed by NFPA 101, Life Safety Code, for health care occupancies

One or more of the checks on Worksheet 4.7.9 are in the “No” column or any considerations in Worksheet

4.7.10 marked as “Not Met” have NOT been evaluated and mitigated to the satisfaction of the AHJ. The level

of safety is not shown by this system to be equivalent to that prescribed by NFPA 101, Life Safety Code, for

health care occupancies.

Form

CMS-2786T (10/2016)

Page

Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code Page 7