This section captures critical location and patient isolation data to establish the scope and risk level of the HVAC emergency. All fields marked mandatory must be completed before proceeding to subsequent sections.
Healthcare Facility Name
Medical Wing/Zone Identifier
Bio-Containment Room Number(s)
Bio-Safety Level (BSL) Classification
BSL-2 Enhanced
BSL-3
BSL-3 Enhanced
BSL-4
Total Number of Patients in Affected Unit(s)
Current Isolation Precautions in Effect (select all that apply)
Contact Precautions
Droplet Precautions
Airborne Precautions
Strict Aseptic Protocol
Enhanced PPE Required
Are patients infected with high-consequence infectious agents?
Exact Time of Pressure/Ventilation Failure Detection
Number of Clinical Staff Present in Unit at Time of Failure
Additional Isolation Metadata or Special Considerations
Document all pressure differential measurements and HEPA filtration system diagnostics. Compare current readings against established baselines to determine deviation severity.
Pressure Differential Measurements (in Pascals)
Location/Room Pair | Required Baseline Pressure | Actual Pressure at Detection | Current Pressure (Post-Initial Response) | Deviation from Baseline | Within Acceptable Tolerance? | |
|---|---|---|---|---|---|---|
Patient Room to Anteroom | -25 | -15 | -18 | 10 | ||
Anteroom to Corridor | -15 | -8 | -10 | 7 | ||
Bathroom to Patient Room | -10 | -5 | -8 | 5 | ||
Primary HEPA Filter Differential Pressure (Pa)
HEPA Filter Integrity Test (PAO/DEHS) Passed?
Supply Air Flow Rate (m³/h)
Exhaust Air Flow Rate (m³/h)
Were any HEPA filter housings or seals visually compromised?
Primary Cause of Pressure Loss
HEPA Filter Loading/Clogging
Fan/Motor Failure
Damper Malfunction
Ductwork Breach
Control System Failure
Power Supply Issue
Multiple Factors
Unknown - Under Investigation
Critical Pressure Alarm Activated?
Additional Diagnostic Observations
Was Emergency Patient Relocation Required?
Relocation Initiation Time (if applicable)
Relocation Completion Time (if applicable)
Destination Relocation Room Number(s)
Patient Condition During Relocation
Stable
Monitored - Minor Concern
Unstable - Required Intervention
Critical - Emergency Support Required
Were patients transported using negative pressure isolation pods?
I confirm that all transport personnel utilized appropriate PPE (N95 or higher, gowns, gloves, eye protection)
Biological Containment Lockdown Initiated
Containment Lockdown Procedures Implemented (select all that apply)
Sealed patient room doors
Activated emergency exhaust fans
Closed corridor dampers
Restricted access to zone
Deployed portable HEPA units
Initiated room decontamination cycle
Established negative pressure anteroom buffer
Was there any breach of primary containment during the incident?
Communication Log: Key Notifications and Responses
Total Staff Exposed to Compromised Environment
Document all mechanical repairs, component replacements, and system recalibration activities. Smoke testing must verify pressure relationships before returning to normal operations.
Mechanical Fault(s) Identified (select all that apply)
Supply fan failure
Exhaust fan failure
Variable Frequency Drive (VFD) malfunction
Control damper stuck closed/open
Ductwork rupture or disconnection
Pressure sensor calibration drift
Building Automation System (BAS) error
Electrical power fluctuation
HEPA filter gasket failure
Repair Actions and Component Replacement Log
Component/System | Repaired | Replaced | Part Number/Serial Number | Action Description | Technician Confidence (1-5) | |
|---|---|---|---|---|---|---|
Primary Supply Fan | Yes | SF-4B-01 | Cleaned and lubricated bearings | |||
HEPA Filter Set A | Yes | HEPA-2938-BC | Replaced due to 3-year service interval | |||
Was smoke testing performed to verify pressure relationships?
Smoke Testing Completion Time
Did smoke testing confirm correct airflow directionality?
Time Required to Restore System to Baseline Pressure (minutes)
Recalibration Settings Adjusted
Were backup or redundant systems activated during repairs?
Post-Repair System Performance Verification
Number of HVAC Technicians Involved in Repair
Final authorization section requiring review and sign-off from both Infection Prevention and Facilities Engineering leadership before the bio-containment unit can return to normal patient care operations.
Infection Prevention Officer Reviewed All Containment Procedures?
Were any staff exposures identified requiring follow-up monitoring?
Infection Prevention Officer Risk Assessment Summary
Infection Prevention Officer Review Completion Time
Infection Prevention Officer Digital Signature
Infection Prevention Officer Name (Printed)
Chief Facilities Engineer Verified All Mechanical Repairs?
Chief Facilities Engineer Technical Validation Comments
Chief Facilities Engineer Sign-Off Time
Chief Facilities Engineer Digital Signature
Chief Facilities Engineer Name (Printed)
Is the bio-containment unit cleared for return to normal operations?
Final Recommendations and Follow-Up Actions Required