Please provide complete legal and operational information for the tenant entity requesting alterations. All fields marked mandatory must be completed for processing.
Entity Name (as on lease)
Doing Business As (DBA) Name
Authorized Representative Full Name
Representative Title
Email Address
Direct Phone Number
Facility Type Classification (select all that apply)
General Medical Clinic
Outpatient Surgery Center
Clinical Laboratory
Pathology Laboratory
Imaging Center
Dental Clinic
Specialty Clinic
Combined Facility
OUTPATIENT SURGERY CENTER: You must complete Section 9 (Outpatient Surgery Specific Requirements) and provide ASC compliance documentation.
CLINICAL LABORATORY: You must complete Section 8 (Laboratory Specific Requirements) and provide biosafety and chemical safety documentation.
PATHOLOGY LABORATORY: You must complete Section 8 (Laboratory Specific Requirements) with emphasis on hazardous biological material handling.
COMBINED FACILITY: You must complete ALL relevant specialty sections (8, 9) that apply to your combined operations.
Building Name
Suite/Unit Number
Floor Number
Total Leased Square Footage (sq ft)
Current Lease Start Date
Current Lease End Date
Current Use of Space
Proposed Use After Alterations
Project Title
Detailed Project Description
Primary Reason for Alteration
Patient Capacity Expansion
Technology/Equipment Upgrade
Regulatory Compliance Update
Infection Control Improvement
Energy Efficiency
Aesthetic Modernization
New Service Line Addition
Safety Enhancement
Requested Construction Start Date
Requested Construction Completion Date
Total Estimated Construction Duration (days)
Proposed Construction Schedule (select all applicable windows)
Weekdays 08:00-18:00
Weekdays 18:00-22:00
Weekends 08:00-18:00
Nights 22:00-06:00
Emergency after-hours only
Will weekend work require HVAC system operation beyond normal building hours?
Will night work require continuous security escort?
Will the project involve adding or removing non-load-bearing partitions?
Describe partition modifications including materials, fire-rating requirements, and locations
Will the project modify any load-bearing walls or structural elements?
Provide detailed structural engineer assessment and proposed modifications
Will ceiling height or configuration be altered?
Describe ceiling modifications including impact on fire sprinkler heads, lighting, and HVAC diffusers
Will flooring materials be changed?
New flooring type
Seamless Vinyl Sheet
Epoxy Resin
Rubber
Carpet Tile
Ceramic Tile
Other
Will doors, frames, or hardware be modified?
Specify door ratings, hardware types (panic, closers, locks), and accessibility compliance
Will accessibility features (ramps, handrails, clearances) be added or modified?
Has a universal design/accessibility consultant reviewed the plans?
Will HVAC systems be modified, upgraded, or rebalanced?
Describe HVAC changes including air changes per hour, filtration upgrades (HEPA?), pressure relationships, and temperature/humidity control
Will the electrical service or distribution be upgraded?
Electrical Load Additions
Equipment Name | Voltage | Amperage | Quantity | Total Watts | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
1 | MRI Scanner | 480 | 100 | 1 | 48000 | |
2 | Surgical Light | 120 | 5 | 3 | 1800 | |
3 | 0 | |||||
4 | 0 | |||||
5 | 0 | |||||
6 | 0 | |||||
7 | 0 | |||||
8 | 0 | |||||
9 | 0 | |||||
10 | 0 |
Will plumbing systems or fixtures be added/relocated?
Describe plumbing changes including domestic water, sanitary waste, acid waste, or specialty systems
Will fire suppression (sprinkler) or fire alarm systems be modified?
Detail fire system modifications including sprinkler head additions, relocations, alarm device changes, and fire marshal approvals
Will medical gas piping or outlets be installed, modified, or removed?
Select all medical gas systems involved
Oxygen (O2)
Medical Air (MA)
Nitrous Oxide (N2O)
Nitrogen (N2)
Carbon Dioxide (CO2)
Medical Vacuum (VAC)
Waste Anesthetic Gas Disposal (WAGD)
Instrument Air
Laboratory Air
Will the project require installation of medical gas alarm panels or zone valves?
Number of new zone valve boxes
Has a certified medical gas installer been engaged?
Installer company name and certification number
Will verification, testing, and certification be completed per applicable standards?
Will emergency power (UPS/generator) systems be added or modified?
Describe emergency power loads, transfer switches, and connectivity to building system
Healthcare construction requires strict infection control. ICRA Type definitions: Type I (low risk, non-patient areas), Type II (medium risk, patient areas, no construction dust), Type III (high risk, active patient care, dust containment required), Type IV (highest risk, critical care, negative pressure required), Type V (pathology labs, biosafety).
ICRA Construction Type Classification
Type I - Non-Patient Areas Only
Type II - Patient Areas, No Dust Generation
Type III - Patient Areas with Dust Containment
Type IV - Critical Areas with Negative Pressure
Type V - Laboratory/Biosafety Environment
Will the construction area require negative pressure isolation?
Required negative pressure differential (inches of water column)
Will patient care operations continue during construction?
Describe patient safety plan including temporary barriers, alternate egress routes, noise mitigation, and communication protocols
Will sterile processing, pharmacy clean rooms, or isolation rooms be impacted?
Detail protective measures and temporary relocation plans
Has an ICRA permit been completed with the facility's infection prevention department?
Upload signed ICRA permit and risk mitigation plan
Risk Assessment Matrix - Rate the potential impact on the following areas
Minimal | Low | Moderate | High | Critical | |
|---|---|---|---|---|---|
Airborne infection risk | |||||
Water supply contamination | |||||
Noise disruption to patient care | |||||
Emergency access obstruction | |||||
Vibration affecting sensitive equipment |
Does this project involve a clinical or pathology laboratory?
Biosafety Level (BSL)
BSL-1 (Standard Microbiology)
BSL-2 (Moderate Risk Agents)
BSL-3 (High Risk, Respiratory)
BSL-4 (Maximum Containment)
BSL-3 and BSL-4 requirements: You must provide detailed containment protocols, HEPA filtration specifications, and independent exhaust systems.
Will fume hoods or biological safety cabinets (BSC) be installed or relocated?
Fume Hood/BSC Schedule
Equipment Type | Make/Model | Face Velocity (fpm) | Connected to Building Exhaust? | Requires Dedicated Exhaust Fan? | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
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10 |
Will hazardous chemicals be stored or used in quantities exceeding standard allowances?
List chemical categories, volumes, storage cabinet types, and spill containment measures
Will laboratory waste systems (acid waste, biological waste) be installed?
Describe waste neutralization, disinfection, and disposal systems
Does this project involve an outpatient surgery or procedure center?
Number of new or modified operating/procedure rooms
Will operating rooms be classified per surgical invasiveness standards?
OR Classification
Class A (Minor Procedures)
Class B (Moderate Invasiveness)
Class C (Major Invasive)
Will anesthesia gas scavenging systems be installed?
Number of WAGD (Waste Anesthetic Gas Disposal) outlets
Will pre-operative and post-anesthesia recovery (PACU) areas be created or modified?
Number of recovery bays
Will sterile processing and instrument decontamination areas be included?
Will these areas meet sterile processing department (SPD) workflow standards (dirty to clean to sterile)?
Will there be dedicated emergency power for life-sustaining equipment in surgery areas?
List equipment on emergency power and required uptime (e.g., 2-hour, 24-hour, 72-hour)
General Contractor Company Name
Primary Contractor License Number
Contractor Safety Officer Contact
Has the contractor completed healthcare facility ICRA training?
Upload ICRA training certificates for all on-site personnel
Will the contractor provide current certificates of insurance (COI) with adequate coverage?
List coverage types and limits (General Liability, Workers Comp, Professional Liability)
Has a comprehensive safety plan been developed?
Upload safety plan including fall protection, electrical lockout, and hazardous materials handling
Will hot work (welding, cutting) be performed?
Has a hot work permit process been established with building management?
Will the project require planned utility shutdowns (power, water, HVAC)?
Utility Shutdown Schedule
Utility Type | Shutdown Start Date & Time | Shutdown End Date & Time | Affected Areas | Patient Care Impact? | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
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Will construction generate noise or vibration affecting adjacent tenants or patient areas?
Describe mitigation measures: sound barriers, vibration isolation, work scheduling
Will there be any temporary occupancy or egress path changes?
Upload temporary life safety plan showing alternate egress routes
Will hazardous materials (asbestos, lead, silica) be disturbed?
Describe abatement procedures and licensed remediation contractor details
Has a communication plan been developed for notifying patients and staff?
Describe notification methods and timeline
Upload architectural demolition and construction drawings (PDF format)
Upload MEP (Mechanical, Electrical, Plumbing) engineered drawings
Upload reflected ceiling plan showing all MEP overlays
Will new medical equipment be installed?
Medical Equipment Schedule
Equipment Name | Manufacturer | Weight (lbs) | Power Requirements | Vibration Sensitive? | ||
|---|---|---|---|---|---|---|
A | B | C | D | E | ||
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Are product specifications and material safety data sheets available?
Upload specifications binder
Have local building authority permits been applied for?
Permit application number
Total Estimated Construction Cost
Architectural & Engineering Fees
Permit & Inspection Fees
Building Management Review Fee (if applicable)
Financial Responsibility per Lease
Tenant Responsible for All Costs
Landlord Contribution per Lease Terms
Shared Cost per Lease Amendment
Landlord Responsible (building systems only)
Has a security deposit or letter of credit been provided for potential building damage?
Will the alteration increase the leasable value and affect future rent?
Describe lease amendment process
I certify that all information provided is accurate and complete to the best of my knowledge
I acknowledge that construction cannot commence until written approval is granted by building management and all required permits are obtained
I confirm that all contractors will comply with building rules, infection control protocols, and safety requirements
Authorized Tenant Representative Signature
Signature Date & Time
FOR BUILDING MANAGEMENT USE ONLY: Review and approval of this request does not constitute waiver of lease provisions or approval of regulatory compliance. Separate permits and inspections are required.
Building Management Reviewer Name
Review Decision
Management Comments & Conditions
Building Management Authorized Signature
To configure an element, select it on the form.