Comprehensive Medical Tenant Alteration Request & Approval System

Entity Name (as on lease)

Doing Business As (DBA) Name

Authorized Representative Full Name

Representative Title

Facility Type Classification (select all that apply)

Building Name

Suite/Unit Number

Current Use of Space

Proposed Use After Alterations

Project Title

Detailed Project Description

Primary Reason for Alteration

Total Estimated Construction Duration (days)

Proposed Construction Schedule (select all applicable windows)

Will the project involve adding or removing non-load-bearing partitions?

Will the project modify any load-bearing walls or structural elements?

Will ceiling height or configuration be altered?

Will flooring materials be changed?

Will doors, frames, or hardware be modified?

Will accessibility features (ramps, handrails, clearances) be added or modified?

Will HVAC systems be modified, upgraded, or rebalanced?

Will the electrical service or distribution be upgraded?

Will plumbing systems or fixtures be added/relocated?

Will fire suppression (sprinkler) or fire alarm systems be modified?

Will medical gas piping or outlets be installed, modified, or removed?

Will the project require installation of medical gas alarm panels or zone valves?

Has a certified medical gas installer been engaged?

Will verification, testing, and certification be completed per applicable standards?

Will emergency power (UPS/generator) systems be added or modified?

ICRA Construction Type Classification

Will the construction area require negative pressure isolation?

Will patient care operations continue during construction?

Will sterile processing, pharmacy clean rooms, or isolation rooms be impacted?

Has an ICRA permit been completed with the facility's infection prevention department?

Risk Assessment Matrix - Rate the potential impact on the following areas

Does this project involve a clinical or pathology laboratory?

Will fume hoods or biological safety cabinets (BSC) be installed or relocated?

Will hazardous chemicals be stored or used in quantities exceeding standard allowances?

Will laboratory waste systems (acid waste, biological waste) be installed?

Does this project involve an outpatient surgery or procedure center?

Will operating rooms be classified per surgical invasiveness standards?

Will anesthesia gas scavenging systems be installed?

Will pre-operative and post-anesthesia recovery (PACU) areas be created or modified?

Will sterile processing and instrument decontamination areas be included?

Will there be dedicated emergency power for life-sustaining equipment in surgery areas?

General Contractor Company Name

Primary Contractor License Number

Contractor Safety Officer Contact

Has the contractor completed healthcare facility ICRA training?

Will the contractor provide current certificates of insurance (COI) with adequate coverage?

Has a comprehensive safety plan been developed?

Will hot work (welding, cutting) be performed?

Will the project require planned utility shutdowns (power, water, HVAC)?

Will construction generate noise or vibration affecting adjacent tenants or patient areas?

Will there be any temporary occupancy or egress path changes?

Will hazardous materials (asbestos, lead, silica) be disturbed?

Has a communication plan been developed for notifying patients and staff?

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?

Are product specifications and material safety data sheets available?

Have local building authority permits been applied for?

Permit & Inspection Fees

Building Management Review Fee (if applicable)

Financial Responsibility per Lease

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?

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

Building Management Reviewer Name

Review Decision

Management Comments & Conditions

Building Management Authorized Signature