Attachment 3: EHRM ICRA

SAFETY PIN

Form Date: 11/4/2024

I. PCRA

Table 1: Activity Type and Control Measures
Table 2: Affected Adjacent Area Assessment
PCRA Permit Form

II. ICRA

Table1: Activity Category
Table 2: Affected Area Assessment
Table 3: Patient Risk Category
Table 4: Level of IP&C Precautions
ICRA Permit Form

III.VA CATEX (NEPA)

CATEX Form
Categorical Exclusions List
IV.ILSM Assessment
ILSM Assessment Form

REQUIRED ATTACHMENTS

(to accompany Safety Pin)

I. Scope of Work Description

II. ILSMRA Form (if applicable)
III.Hot Work Permit (if applicable)
IV.SHPO form (if applicable)

VHA Pre-Construction Risk Assessment (PCRA)
Return to TOC

PCRA Introductory Information and Instructions

Use this template as a baseline for performing facility Pre-Construction Risk Assessments (PCRA) for Construction, Renovation, and Maintenance work (referred to as the “activity” in this document). The template provides minimum requirements for categorizing activity type(s) and safety risk to determine the level of precautions needed to prevent impact related to Construction, Renovation and Maintenance on patients, employees, and contractors.
Ensure that the activity statement of work and any drawings available are used for the PCRA assessment and included in the project file with the completed PCRA.
Communication and coordination of all types of activity with affected areas are to be included among the control measures. The development of communication and coordination plans must begin during the activity planning phase.
Facilities may customize this template to incorporate site-specific information and requirements. NOTE: This VHA PCRA template pertains specifically to non-infection-related safety for Construction, Renovation, and Maintenance activities. It must be used in conjunction with the VHA Infection Control Risk Assessment (ICRA) for the activity, if required, which specifically addresses infection risks outside the scope of this PCRA.
PERMIT: See the last page of this document for a fillable permit form to be used for posting at the activity site. Activity
Location:

Dallas VA Consolidated Mail Outpatient Pharmacy

Activity Name, Number,
and/or Brief Description:

EHRM Infrastructure Upgrades

Table 1 - Construction, Renovation, and/or Maintenance Activity Type and Control Measures NOTE: If any of the bulleted criteria in a higher activity type pertains to the work that will be done (even if the other criteria are in a lower type), use the higher activity type for the VHA PCRA.