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Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 2

PART I - INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786V)

(SMALL FACILITIES — 16 BEDS OR LESS)

EXISTING OCCUPANCIES

1. Complete the “Worksheets for Determining Evacuation Capabilities” (CMS-2786M) for each resident in the facility.

Note: Completing these worksheets is the ONLY method permitted for determining Evacuation Capabilities.

2. Transfer the calculated E-Score obtained in Worksheet 6.8.10 to the E-SCORE block (Page 1 of this form).

3. Determine the Level of Evacuation Capability, obtained in Worksheet 6.8.11 (i.e., Prompt, Slow or Impractical).

4. Complete a survey using Part II –Existing Residential Board & Care Occupancies of this form for compliance with the NFPA 101,

Chapter 33.

If Level of Evacuation Capability is:

1. PROMPT - Complete Part III PROMPT EVACUATION section ONLY.

2. SLOW - Complete Part III PROMPT and SLOW EVACUATION sections.

3. IMPRACTICAL - Complete all three sections, Part III PROMPT, SLOW, and IMPRACTICAL.

5. Complete the Part IV – Building Services section.

6. Complete the Part V – Operating Features section.

NEW OCCUPANCIES

1. Complete a survey using Part III – New Residential Board & Care Occupancies of this form for compliance with the NFPA 101,

Chapter 32.

2. Complete the Part IV – Building Services section.

3. Complete the Part V – Operating Features section.

OPTIONAL FIRE SAFETY EVALUATION SYSTEM

Use CMS - 2786Y and r eference NFPA 101A – Fire Safety Evaluation System for Board and Care Occupancies (Chapter 7).

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Form CMS-2786V (10/2016)

Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 2