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Form Cms-2786m - Worksheet For Determining Evacuation Capability - Icf-Iid (Existing Facilities Only) 2012 Life Safety Code

2012 LIFE SAFETY CODE

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB Exempt

WORKSHEETS FOR DETERMAINING EVACUATION CAPABILITY

Intermediate Care Facilities for Individuals with Intellectual Disabilities

(APPLICABLE TO EXISTING FACILITIES ONLY)

(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)

Before completing these worksheets, read Chapter 6 of NFPA 101A, 2013 Edition, Evacuation Capability Determination for

Board and Care Occupancies.

PART I – WORKSHEETS FOR RATING RESIDENTS

Complete Worksheets 6.8.1, 6.8.2, and 6.8.3, and determine the Evacuation Assistance Score for each resident in the

facility.

WORKSHEET 6.8.1 – COVER SHEET FOR RATING THE RESIDENTS

ZONE

ZONES

NAME OF FACILITY

ADDRESS OF FACILITY

ZONE(S) EVALUATED

PROVIDER/VENDOR NO.

DATE OF SURVEY

SURVEYOR SIGNATURE

DATE

TITLE

OFFICE

SURVEYOR ID

FIRE AUTHORITY SIGNATURE

TITLE

OFFICE

DATE

ADDITIONAL COMMENTS:

CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD

Form CMS-2786M (10/2016)

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Form Cms-2786m - Worksheet For Determining Evacuation Capability - Icf-Iid (Existing Facilities Only) 2012 Life Safety Code