DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE ICFs/MR Form Approved OMB No. 0938-0242 1. (A) PROVIDER NO. 1. (B) MEDICAID I.D. NO. K1 FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded APARTMENT HOUSE K2 PART I — 32 or 33 — Residential Board & Care Occupancies — Requirements PART II — 7.7 (101A, 2001) — Fire Safety Evaluation System for Board & Care (Optional) Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS) 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. A. BUILDING ________________ B. WING B. ________________ 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER: 9. K4 E-Score ≤ 1.5 s None (No sprinkler system) K0180 K3 E-SCORE s Partially Sprinkleredsprinklered) (Not all required areas are C. ________________ C. FLOOR s Fully Sprinklered sprinklered) (All required areas are K6 Level of Evacuation Difficulty Prompt > 1.5 ≤ 5.0 s Chapter 32 New s Chapter 33 Existing K7 5. SURVEY FOR CERTIFICATION OF: APARTMENT HOUSE LEVEL OF EVACUATION DIFFICULTY (check one) Slow > 5.0 s 2000 7. s Prompt 8. s Slow 9. s Impractical Impractical K5 K8 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID s THE FACILITY MEETS, BASED UPON (check all appropriate boxes): 1. s COMPLIANCE WITH ALL PROVISIONS 2. s ACCEPTANCE OF A PLAN OF CORRECTION B. s THE FACILITY DOES NOT MEET THE STANDARD e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID 7. A. 4. s FSES 5. s PERFORMANCE BASED DESIGN K9 SURVEYOR (Signature) TITLE OFFICE DATE TITLE OFFICE DATE SURVEYOR ID K10 FIRE AUTHORITY OFFICIAL (Signature) According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. FORM CMS-2786X (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING THIS FORM (CMS-2786X) SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY 1. FIRST complete FORM CMS-2786Y (Small Facility Survey Report) 2. NEXT complete THIS form, to rate the suitability of the Apartment Building to House a Board and Care Occupancy. NOTE: The items on this form refer to the part of the building the Board and Care Occupancy (Apartment). 3. If using NFPA 101A Figure 7.7 — FSES/BC — Rating the Building, complete Part I of this form FIRST. NOTE: When using this form, you must also complete a CMS 2786Y. FORM CMS-2786X (06/07) EF 06/2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE NOTE: You must complete a CMS-2786Y for each Apartment unit with a Board & Care Occupancy. BUILDING CONSTRUCTION K12 Minimum Construction Requirements: (Based on highest story normally used by residents) PROMPT and SLOW One and Two Story u Any construction type of one-hour or greater fire rating or, u Type IV (2HH) or, u Fully sheathed or, u With automatic sprinkler system throughout, in accordance with Section 9.6 and 9.7. u Exception: One story any construction type and no more than 30 residents capable of prompt evacuation. Three to Six Stories u Type I, II or III construction of one-hour or greater fire rating or, u Type IV construction with automatic sprinkler system throughout in accordance with Section 9.6 or 9.7. u Exception: Three or four story facilities of type V (000), sheathed and with automatic sprinkler system throughout, in accordance with Sections 9.6 and 9.7. More than Six Stories u Type I or II (222) construction or, u Type II (111) construction or, u Type III (211) construction or, u Type IV (2HH) with automatic sprinkler system throughout in accordance with Sections 9.6 and 9.7. Minimum Construction Requirements: (Based on highest story normally used by residents) PROMPT and SLOW u Type I or II (222) construction, beyond 75 feet in height with automatic sprinkler protection throughout in accordance with Section 9.6 and 9.7. u Type II (111) construction, limited to three stories with automatic sprinkler protection throughout in accordance with Sections 9.6 and 9.7 u Type II (000), III (211), IV (2HH), V (111) limited to one story with automatic sprinkler protection throughout in accordance with Section 9.6 and 9.7. 32.3.1.3, 33.3.1.3 FORM CMS-2786X (06/07) EF 06/2007 Page 3 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE HAZARDOUS AREAS (Outside B & C Units) K29 Where buildings are without suppression or detection systems, or have total automatic detection or partial sprinkler protection every hazardous area shall be separated by construction of one-hour fire rating. Openings shall be protected by smoke-actuated automatic or self-closing fire doors, with a 3/4 hour fire rating or the area is equipped with an automatic sprinkler system. Hazardous areas include, but are not limited to: u Boiler and heater rooms u Laundries u Repair shop u Rooms or spaces used for storage of combustibles or equipment deemed hazardous by the authority having jurisdiction. Where buildings have an automatic extinguishment system installed in accordance with NFPA 13, areas may be smoke-resisting construction. 30.3.2, 31.3.2, 8.4 K211 2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 483.470 FORM CMS-2786X (06/07) EF 06/2007 Page 4 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX K211 SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE 2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 483.470 MANUAL FIRE ALARM K51 Apartment buildings with more than three stories or more than eleven units shall have a fire alarm system, not a presignal type, with occupant notification accomplished automatically and without delay in accordance with Section 9.6, 30.3.4, 31.3.4. An annunciator panel shall be provided. 31.3.4.3.2. K155 Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown untilt e fire alarm system has been returned to service. 9.6.1.8 SMOKE DETECTION AND ALARM (Outside B & C) K109 Every living unit within the apartment building regardless of number of stories, number of apartments, sprinkler system or other detection system shall have approved single or multiple station smoke detectors installed, powered by house electrical service. u Exception: Where the building is equipped with a total automatic smoke detection system throughout. 30.3.5, 31.3.4.4 FORM CMS-2786X (06/07) EF 06/2007 Page 5 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE AUTOMATIC SPRINKLER (Outside B & C) K56 Where buildings are required to be protected throughout by an approved automatic sprinkler system and where a partial system is required, the system shall be in accordance with Section 9.7. 30.3.5 K64 Portable fire extinguishers shall be provided in hazardous areas in accordance with Section 9.7.4.1 unless the building is provided with an appropriate supervised automatic sprinkler system. 30.3.5.7 K154 Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1 A. Date sprinkler system last checked and necessary maintenance provided. _____________________________________________ B. Show who provided the service. __________________________ C. Note the source of the water supply for the automatic sprinkler system._______________________________________________ (Provide, in REMARKS, information on coverage for any non-required or partial automatic sprinkler system.) SEPARATION OF B. C. UNIT AND ITS EXIT ROUTES K38 2000 EXISTING Exit access corridors shall be protected as follows: u 1. Where buildings do not have an automatic sprinkler or detection system, corridor walls shall have one-hour fire rating. u 2. Where buildings have a partial sprinkler or detection system, corridor walls shall have 3/4 hour fire rating. u 3. Where buildings have an automatic sprinkler system through, corridor walls shall have 1/2 hour fire ratings. 31.3.6 FORM CMS-2786X (06/07) EF 06/2007 Page 6 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE 2000 New Exit access corridor walls shall consist of fire barriers in accordance with 8.2.3 that have no less than 1/2 hour fire resistance rating. Exception: In buildings protected throughout by an approved automatic sprinkler system in accordance with 29.3.5, no fire resistance rating shall be required, but the walls and all openings therein shall resist the passage of smoke. 30.3.6, 32.4.2, 31.3.6 K18 Doors between apartments and corridors shall be self-closing and have a minimum 20 minute fire rating. 30.3.6.2, 31.3.6.2 EXIT SYSTEM K32 At least two acceptable exits, remote from each other, are provided for each floor or fire section. At least half of the required number of units of exit width shall lead directly to the street. u Exception No. 1: A living unit with direct exit to street at ground level or an outside stairway or an enclosed stairway, of one hour fire rating, serving that unit only, may have a single exit. u Exception No. 2: Where there are a maximum of four living units per floor with no more than 20 feet from each unit’s entrance door to an exit, may have a single exit of a smokeproof tower or outside stair in accordance with 5.2.3. u Exception No. 3: Where there is no more than three stories and living units are separated, vertically and horizontally by 3/4 hour fire rating, may have a single exit if the stairway is of one hour construction, serving as access with a maximum of 35 feet from each unit’s entrance door to exit. 7.3, 30.2.4, 31.2.4, 32.3.2.4 K35 Capacity of exits in number of persons per unit of exit width is in accordance with 7.3. 30.2.3.1, 31.2.3.1 EXIT ACCESS K36 Travel distance from the door of a room in a living unit to a corridor door and a living unit entrance door to the nearest exit are in accordance with Table A.31.1. 30.2.6. FORM CMS-2786X (06/07) EF 06/2007 Page 7 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE INTERIOR FINISH K14 Interior finish on walls, ceilings and floors are in accordance with and shall apply to the parts of means of egress serving the apartments used as a residential board and care occupancy. 30.3.3, 31.3.3. VERTICAL OPENINGS K20 Stairways, elevator shafts and other vertical openings are in accordance with 30.3.1, 29.3.1, 31.3.1 SMOKE CONTROL K24 Exit access corridors shall be provided with smoke barriers in accordance with Section 8.3. The maximum length of each smoke compartment shall be 200 feet. Smoke dampers are not required. u Exception No. 1: Where buildings have an automatic sprinkler system throughout. u Exception No. 2: Where exit access is through an atrium 8.2.5.6. u Exception No. 3: Where exterior exit access provides access to two exits 7.5.3. u Exception No. 4: Buildings complying with 31.3.7, Exceptions 1,2, and 3. u Exception No. 5: Buildings with exits maximum 50 feet apart. u Exception No. 6: Where each dwelling unit has direct access to exterior at grade. 31.3.7, 33.4.3.3. K44 Horizontal exits required to limit maximum gross area shall be as specified in 7.2.4.2. 31.2.2.5 SPECIAL FEATURES K126 Where buildings are greater than six stories with 1 total automatic fire detection system per N.F.P.A. 72E, but without an automatic sprinkler system, the interior exit access corridors shall be continuously pressurized at a minimum of 0.01 inches water, measured at any living unit door. 31.2.11, 7.2.3 FORM CMS-2786X (06/07) EF 06/2007 Page 8 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE BUILDING SERVICES EQUIPMENT K117 Utilities shall comply with provision of Section 9.1. 32.3.6.1, 33.3.6.1. K67 Heating, ventilating and air conditioning equipment shall comply with the provisions of Section 9.2. 32.3.6.2, 33.3.6.2 K118 Elevators, dumbwaiters and vertical conveyors shall comply with the provisions of Section 9.4. 32.3.6.3, 32.3.6.3.2, 33.3.6.3 K71 Rubbish chutes, incinerators and laundry chutes shall comply with the provisions of Section 9.5. 32.3.6.4, 33.3.6.4 OPERATING FEATURES K127 Every required automatic sprinkler system, fire detection and alarm system, smoke control system, exit lighting, fire door and other item of equipment required by this code shall be continuously maintained in proper operating condition. 4.6.12 K72 No furnishings, decorations or other objects are placed to obstruct exits or visibility of exits. 7.5.2.2 32.7.5 K73 No furnishings or decorations of an explosive or highly flammable character are used. 18.7.5.4, 19.7.5.4 EMERGENCY PLAN, FIRE DRILLS K48 There is a written plan for the protection of all persons and for their evacuation in the event of an emergency. All employees shall be instructed and reviewed as to their duties and responsibilities under the plan. 32.7.1, 33.7.1 FORM CMS-2786X (06/07) EF 06/2007 Page 9 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX K128 SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY MET NOT MET N/A REMARKS APARTMENT HOUSE All residents capable of assisting in their evacuation shall be trained in the proper actions to take in the event of a fire. 32.7.2, 33.7.2 K50 Fire exit drills shall be conducted twelve times per year, quarterly on each shift. Drills shall involve actual evacuation to a selected assembly point and provide experience in exiting through all exits. Exits not used in any fire drill shall not be credited in meeting the requirements of the code. 42 CFR 483.470 Subpart L K66 Where smoking is permitted, noncombustible safety-type ash trays or receptacles shall be provided in convenient locations. 32.7.4, 33.7.4 ILLUMINATION AND EMERGENCY POWER K45 Every public space, hallway, stairway and other means of egress shall have illumination in accordance with Section 7.8. 30.2.8, 31.2.8 K46 Any apartment building with more than twelve living units or greater than three stories shall have emergency lighting in accordance with Section 7.8. u Exception: Where every living unit has a direct exit to the outside at grade level. K47 Signs marking means of egress shall be in accordance with section 7.10 and provided in all apartment buildings requiring more than one exit. 30.2.10, 31.2.10 FORM CMS-2786X (06/07) EF 06/2007 Page 10 American LegalNet, Inc. www.FormsWorkflow.com FIRE SAFETY EVALUATION WORKSHEET FOR AN APARTMENT BUILDING WITH BOARD AND CARE OCCUPANCIES G3 Building Identification ____________________________________________________________________________________________________ Evaluator ________________________________________________________________Date ___________________________________________ (Complete one worksheet for each apartment house containing one or more apartment units with a board and care occupancy.) First complete Table 7.7. Continue with Fig. 7.7.1 through 7.7.5. Then return to this page to obtain the Equivalency Conclusions. TURN TO NEXT PAGE Part 3E. Equivalency Conclusions Complete Tables 7.7.2 through 7.7.7 before doing this part. 1. u All of the checks in Table 7.7.7 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed for apartments.* 2. u One or more of the checks in Table 7.7.7 is in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed by the Life Safety Code for apartments. *The equivalency covered by this worksheet includes the majority of considerations covered by the Life Safety Code. There are a few considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in the “Facility Fire Safety Requirements Worksheet.” One copy of this separate worksheet is to be completed for each facility. FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET CONSIDERATIONS MET NOT MET N/A A. Utilities comply with provisions of 9.1 B. Heating, ventilating, and air conditioning equipment comply with provisions of 9.2. C. Elevators, dumbwaiters, and vertical conveyors comply with the provisions of 9.4. D. Rubbish chutes, incinerators, and laundry chutes comply with the provisions of 9.5. E. Complies with the applicable requires of 32.7, 33.7 (Operating Features). FORM CMS-2786X (06/07) EF 06/2007 Page 11 American LegalNet, Inc. www.FormsWorkflow.com Table G-3A Worksheets for evaluating fire safety for an apartment building with board and care occupancies. WORKSHEET 7.7.1 COVER SHEET Fire Safety Evaluation Worksheet for an Apartment Building with Board and Care Occupancies Building Identification ____________________________________________________________________ Evaluator _________________________________________Date _________________________________ WORKSHEET 7.7.2 SAFETY PARAMETER VALUES — APARTMENT BUILDING Safety Parameters Parameter Values Combustible 1. Construction Building Height 1 Story 2 Stories 3-4 Stories 5-6 Stories Over 6 Stories 2. Hazardous Areas (outside board & care home units) 3. Manual Fire Alarm 4. Smoke Detection and Alarm (outside board & care home units) 5. Automatic Sprinklers (outside board & care home units) 6. Separation of Board & Care Home Unit and Its Exit Route from Other Spaces 7. Exit System (serving board & care home units) 8. Exit Access (serving board & care home units) 9. Interior Finish (egress routes serving board & care home units) FORM CMS-2786X (06/07) EF 06/2007 Noncombustible Type V (000) Type V (111) Type III (200) Type III (211) Type IV (2HH) Type II (000) Type II (111) -2( )a -6( )a -8( )a -8 -10 0 0 -2(0)k -2(0)k -4 Double Deficiency -4(-7)b.g None or Incomplete 0(2)i -2( )a -6( )a -8( )a -8( )a -10 0 0 0 0 -2(0)k 0 0 -2(0)k -2(0)k -4(0)k 0 -5( )a -6( )a -6( )a -8 2 2 2 2 0 None or No Deficiency 0 Single Deficiency 0(-4)g Type II (222) & Type I 2 2 2 2 2 Manual Alarm w/o F.D. Notification w/F.D. Notification 2 3 Interconnected System Single Station Corrs. & Corrs., Common None or Living Units Only Common Spaces, & Living Total Incomplete Single Level Every Level Spaces Units Building -4(0)j 0 -2(0)e -3(0)3 4 6 None or Corrs., Public Living Units Corrs., Hab., & Total Incomplete Space Only Public Spaces Building 4(0)c 6 8 0 2(0)c Walls 30 min to 1 hr Doors20 Doors20 Doors 20 None or min w/o min w/o min min min min Incomplete Closer Closer w/Closer w/Closer w/Closer w/Closer 1(-2)b 2(-2)b 1(-2)b 4(-2)b -6 -2 0(-2)b 50 ft and >50 ft or corridor >150 ft >100 ft >50 ft to 200 ft to 75 to 25 to 0 Egress Provided (S2) minus Required Egress (Sb) > 0 Refuge Provided (S3) minus Required Refuge (Sc) > 0 General Fire Safety (S4) minus Required General Fire Safety (Sd) > 0 NO – = Sb S2 – = Sc S3 – = Sd S4 – = WORKSHEET 7.7.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET CONSIDERATIONS A. NOT MET N/A Utilities comply with the provisions of 32.3.6.1 and 33.3.6.1. B. MET Heating, ventilating, and air conditioning equipment comply with the provisions of 32.3.6.2 and 33.3.6.2, except for enclosure of vertical openings, which have been considered in Safety Parameter 10 of Worksheet 7.7.2. Elevators, dumbwaiters, and vertical conveyors comply with the provisions of 32.3.6.3 and 33.3.6.3. C. D. Rubbish chutes, incinerators, and laundry chutes comply with the provisions of 32.3.6.4 and 33.3.6.5. E. Complies with the applicable requirements of Sections 32.7 and 33.7. All references are to NFPA 101, Life Safety Code WORKSHEET 7.7.7 CONCLUSIONS 1. u All of the checks in Worksheet 7.7.5 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed by NFPA 101, Life Safety Code, for apartments to house a board and care occupancy.* 2. u One or more of the checks in Worksheet 7.7.5 are in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed by NFPA 101 for apartments to house board and care occupancy. *The equivalency covered by this worksheet includes the majority of considerations covered by NFPA 101, Life Safety Code. There are some considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in Worksheet 7.7.6, “Facility Fire Safety Requirements Worksheet.” One copy of this worksheet is to be completed for each facility. FORM CMS-2786X (06/07) EF 06/2007 Page 15 American LegalNet, Inc. www.FormsWorkflow.com FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER FACILITY NAME SURVEY DATE K1 K6 * K4 K3 DATE OF PLAN APPROVAL MULTIPLE CONSTRUCTION TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING LSC FORM INDICATOR ____________ 12 13 14 15 SMALL (16 BEDS OR LESS) K8: ASC Form 2000 EXISTING 2000 NEW 1 PROMPT 2 SLOW 3 IMPRACTICAL LARGE K8: ICF/MR Form 2786V, W, X 2000 EXISTING 2786V, W, X 2000 NEW 16 17 SELECT NUMBER OF FORM USED FROM ABOVE *K9: 7 PROMPT 8 SLOW 9 IMPRACTICAL ENTER E – SCORE HERE (Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.) K29: 4 PROMPT 5 SLOW 6 IMPRACTICAL APARTMENT HOUSE K8: * K7 BUILDING WING FLOOR APARTMENT UNIT COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 Health Care Form 2786R 2000 EXISTING 2786R 2000 NEW 2786U 2786U A B C D K5: K56: e.g. 2.5 FACILITY MEETS LSC BASED ON (Check all that apply) A1. (COMP. WITH ALL PROVISIONS) A2. A3. (ACCEPTABLE POC) FACILITY DOES NOT MEET LSC (WAIVERS) A5. (FSES) (PERFORMANCE BASED DESIGN) K0180 A. B. A4. FULLY SPRINKLERED B. PARTIALLY SPRINKLERED (All required areas are sprinklered) (Not all required areas are sprinklered) C. NONE (No sprinkler system) * MANDATORY FORM CMS-2786X (06/07) EF 06/2007 Page 16 American LegalNet, Inc. www.FormsWorkflow.com