IDPH Project Submission Form

Project Submission Form for Hospitals

Project identifying information

All sections of this form must be completed.    Altered forms will not be accepted

IDPH Number

Facility name

Street address

City
IL
ZIP code

Project name

If this project changes the facility's licensed bed count by adding or reducing beds, it will be necessary to contact the Health Facilities Services and Review Board.

Is this a phased occupancy project? Yes No

If yes, attach an occupancy schedule describing the rooms to be occupied in each phase with a small scale graphic plan

Type of project

new/replace facility renovation/update to existing facility addition to existing facility

PPS rehab unit PPS psychiatric unit Safety Net/Community hospital grant

Type of submission

design development drawings, first stage construction/working drawings, second stage

Certificate of Need

Submit a copy of the approved certificate of need (CON). A review by the Department WILL NOT begin until a CON or appropriate documentation is received. Written documentation from the Health Services and Review Board may be requested indicating a CON is not required.

CON project number
Date approved

Functional program narrative

Provide a functional program narrative for the project that describes the purpose of the project, departmental relationships, space requirements and other basic information relating to fulfillment of the facility's objectives. The functional program shall include a description of those services necessary for the complete operation of the facility.

Attach additional sheets if needed.

Systems program narrative

Provide a systems program narrative describing all special systems including, but not limited to, fire alarm, nurses call, special locking devices, security packages, electrical, plumbing, HVAC, medical gas and fire protection.

Attach additional sheets if needed.

Estimated project cost

1. Site preparation costs $

2. Demolition costs $

3. Construction contracts (including cost of materials) $

4. Change orders $

Subtotal - lines 1 thru 4 $

6. Fixed capital equipment* $

Add lines 5 and 6 $

If the fixed capital equipment is not more than 51 percent of the total cost, then use line 7 for the plan review fee calculation below.

8. If line 6 is 51 percent more than line 7, then multiply line 6 by .20 $

9. Add lines 5 and 8: this is your adjusted estimated project cost $

Plan review fee calculation

The plan review fee is due and payable upon submission of this form along with the drawings and required information. Using the figures in line 7 or line 9, whichever is applicable, calculate the plan review fee.

Estimated project cost Fee as listed below

Less than $500,000 No fee

$500,000 - $999,999 Project cost x .0096 = or $6,000, whichever is greater

$1,000,000 - $4,999,999 Project cost x .0022 = or $9,600, whichever is greater

Greater than $5,000,000 Project cost x .0011 = or $11,000, whichever is greater; maximum fee of $40,000

10. Plan review fee to be submitted $

11. Is the facility a disproportionate share hospital? Yes No

12. Is the facility a rural hospital with 75 beds or less? Yes No

13. If line 11 or line 12 is "yes", reduce line 10 by 50 percent. $

14. Total from line 10 or line 13 (whichever is applicable) $

Remittance should be made payable to the IDPH Plan Review Fund in the form of a check or money order

Mail completed submission to

Design and Construction Section, Illinois Department of Public Health
525 W. Jefferson Street., Fourth Floor, Springfield, IL 62761
217-785-4264

For questions, please call

Drawing submission Provide one set of signed/sealed drawings and outline specifications for review in accordance with Section 250.2430 of the Illinois Hospital Licensing Requirements. This includes design development drawings and outline specifications and working/construction drawings and specifications.

Important notice The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Public Act 90-0327. Disclosure of this information is mandatory.

Code analysis information for EXISTING BUILDING for a renovation/remodel project

Provide the NFPA 220 construction type for the existing building in which the renovation/remodel is occurring.

Construction type
Year built
Number of stories
Height in feet

The information provided on the existing building relates to a new addition code analysis on the next page.

Provide the following information to describe how the existing building meets the above noted construction type:

Sprinkler system

Full Partial Dry Wet None Fire pump capacity Water main size

Emergency power

Type

Generating set UPS Other Fuel storage in gallons

Fire alarm

Direct F.D. connection Remote station Proprietary protective Coded Supervisory

Code analysis information for NEW CONSTRUCTION of a new building or addition to the existing building.

Provide the NFPA 220 construction type for the new construction. Complete the code analysis information on the existing building that the new construction is connected to or adjacent to on the previous page under EXISTING BUILDING.

Construction type
Number of stories
Height in feet

Provide the following information for the new building construction and/or addition(s):

Sprinkler system

Full Partial Dry Wet None Fire pump capacity Water main size

Emergency power

Type

Generating set UPS Other Fuel storage capacity

Fire alarm

Direct F.D. connection Remote station Proprietary protective Coded Supervisory

Contact Information

Facility representative's name
Title

Address

City
State
ZIP code

Phone number
Fax number

E-mail address

Architectural firm name

Project architect

Address

City
State
ZIP code

Phone number
Fax number

E-mail address

HVAC design company

Contact name

Address

City
State
ZIP code

Phone number
Fax number

E-mail address

Electrical system design company

Contact name

Address

City
State
ZIP code

Phone number
Fax number

E-mail address