Healthcare OR Expansion Sign Off Form

Healthcare OR Expansion Sign Off Form

Project Identification

Project Name:

Project Contact

Patient Impact (if applicable)

Patient Name:

Will expansion affect currently scheduled patients?   Yes   No

Clinical & Operational Readiness

Anesthesia readiness confirmed: Yes

Sterile processing capacity confirmed: Yes

Biomedical commissioning complete: Yes

Infection Control & Environmental

Air handling / HVAC verification complete: Yes

Environmental cleaning protocol confirmed: Yes

Staff Training & Competency

Staff training completed for expanded OR capacity: Yes

Regulatory & Financial Approvals

Required permits and inspections obtained: Yes

Fire safety approval obtained: Yes

Budget approved for activation: Yes

Privacy / HIPAA Acknowledgment

Any patient information used in planning, scheduling, or testing has been handled in accordance with applicable privacy policies and institutional procedures for protected health information. Disclosure is limited to personnel with a need to know for operational readiness.

Acknowledgment of privacy compliance: I acknowledge that PHI handling complies with institutional privacy policies

Final Certification

By signing below, the Approver certifies that to the best of their knowledge the information provided in this form is complete and accurate, that required clinical, infection control, biomedical, safety and regulatory reviews have been completed, and that activation of expanded operating room capacity is authorized subject to any conditions noted above. The Approver acknowledges continuing responsibility for monitoring clinical safety and regulatory compliance following activation.

Sign Now