TIM PENCEGAHAN DAN PENGENDALIAN INFEKSI

RUMAH SAKIT SUMBER SENTOSA

Jl. Raya Kebonsari 221 Tumpang-Malang
Telp. 0341-787233 Fax: (0341) 786756
Email: rsss@rocketmail.com

Infection Control Construction Permit

Permit No :

Location Construction : Project Start Date :

Project Coordinator : Estimated Duration :

Contractor Performing Work : Permit Exp Date :

Supervisor : Telephone :

Yes No Constuction Activity Yes No Infection Control Risk

Group

Type A : Inspection, Non Group 1 : Low Risk

invasive activity

Type B : small scale, short Group 2 : Medium Risk

duration, moderate to high
levels

Type C : Activity generates Group 3 : Medium / High

moderate to high levels of dust, Risk
requires greater 1 work shift for
completion

Type D : Major duration and Group : Highest Risk

construction activities.
Requiring consecutive work
shifts.

Class I 1. Execute work by methods to 3. Minor Demolition for

minimize raising dust from Remodelling
construction operations
2. Immediately replace any ceiling
tile displaced for visual inspection

Class II 1. Provides active means ti prevent 6. Contain construction waste

air-borne dust from dispersing
into atmosphere
2. Water mist work surfaces to
control dust while cutting
3. Seal unused doors with duct tape
4. Block off and seal air vents
5. Wipe surfaces with cleaner /
desinfectant
before transport in tightly
covered containers
7. Wet mop and /or vacuum with
HEPA filtered vacuum before
leaving work area
8. Place dust mat at entrance amd
exit of work area
9. Isolate HVAC system in areas
where work is being
performed; restore when work
completed
 TIM PENCEGAHAN DAN PENGENDALIAN INFEKSI
RUMAH SAKIT SUMBER SENTOSA
Jl. Raya Kebonsari 221 Tumpang-Malang
Telp. 0341-787233 Fax: (0341) 786756
Email: rsss@rocketmail.com

Class III 1. Obtain infection control permit 6. Vacuum work with HEPA
before construction begins filtered vacuums
2. Isolate HVAC system in area 7. Wet mop with cleaner /
where work is being done to disinfectant
prevent contamination of the dust
system 8. Remove barriers materials
carefully to minimize
3. Complete all critical barriers or spreading of dirt and debris
implement control cube method associated with construction
before construction
9. Contain construction waste
4. Maintain negative air pressure before transport in tughly
within work site utilizing HEPA covered containers
equipped air filtration unit
5. Do not remove barriers from work
area until complete project is 10. Cover transport receptacles or
checked by Infection Prevention carts. Tape covering
and Control thoroughly cleaned
11. Upon completion, restore
by environmental services
HVAC system where work
was performed

Class IV 1. Obtain infection control permit 8. Do not remove barriers from

before construction begins work area until complete
project is checked by Infection
2. Isolate HVAC system in area Prevention and Control
where work is being done to thoroughly cleaned by
prevent contamination of the dust environmental services
system
9. Vacuum work with HEPA
3. complete all critical barriers or filtered vacuums
implement control cube method
before construction 10. Wet mop with cleaner /
disinfectant
4. Maintain negative air pressure
within work site utilizing HEPA 11. Remove barriers materials
equipped air filtration unit carefully to minimize
spreading of dirt and debris
5. Seal holes, pipes, conduits, and associated with construction
punctures appropriately
12. Contain construction waste
6. Construct anteroom and require before transport in tughly
all personel to pass through this covered containers
room so they can be vacuumed
using HEPA vacuum cleaner 13. Cover transport receptacles or
before leaving work site or they carts. Tape covering
can wear cloth or paper cover all
that are removed each time they 14. Upon completion, restore
leave the work site HVAC system where work
was performed
7. All personel entering work site
are required to wear shoe covers

Additional requirement :
 TIM PENCEGAHAN DAN PENGENDALIAN INFEKSI
RUMAH SAKIT SUMBER SENTOSA
Jl. Raya Kebonsari 221 Tumpang-Malang
Telp. 0341-787233 Fax: (0341) 786756
Email: rsss@rocketmail.com

Date Initial :

Permit request by : Permit authorized by :

Date : Date :