Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code Page 41
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41PART VI - FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS 2786 FORMS)
Provider Number
Facility Name
Survey Date
K1
*K4
K6
DATE OF PLAN
K3
MULTIPLE CONSTRUCTION
A. BUILDING
APPROVAL
B. WING
TOTAL NUMBER OF BUILDINGS ______
C. FLOOR
NUMBER OF THIS BUILDING _______
D. APARTMENT UNIT
LSC FORM INDICATOR
COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,
EXISTING
HEALTH CARE FORM
SMALL
(16 BEDS OR LESS)
12
2786R
2012 EXISTING
1. PROMPT
13
2786R
2012 NEW
2. SLOW
K8
3. IMPRACTICAL
AHCO FORM
LARGE
14
2786U
2012 EXISTING
4. PROMPT
15
2786U
2012 NEW
5. SLOW
K8
6. IMPRACTICAL
ICF/IID FORM
APARTMENT HOUSE
16
2786V, W, X
2012 EXISTING
7. PROMPT
17
2786V, W, X
2012 NEW
8. SLOW
K8
9. IMPRACTICAL
*K7
SELECT NUMBER OF FORM USED FROM ABOVE
COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,
EXISTING
(Check if K321 or K351 are marked as not applicable
in the 2786 M, R, T, U, V, W, X, and Y.)
ENTER E – SCORE
K321:
K351:
e.g. 2.5
K5:
*K9
FACILITY MEETS LSC BASED ON (Check all that Apply)
A1.
A2.
A3.
A4.
A5.
(COMP. WITH ALL
(ACCEPTABLE POC)
(WAIVERS)
(FSES)
(PERFORMANCE
PROVISIONS)
BASED DESIGN)
FACILITY DOES NOT MEET LSC
K0180
A.
B.
C.
B.
FULLY SPRINKLERED
PARTIALLY SPRINKLERED
NONE
(All required areas are
(Not all required areas are
(No sprinkler system)
sprinklered)
sprinklered)
*MANDATORY
Page 41
Form CMS-2786V (10/2016)
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