Project Submission Form for Hospitals

Project Submission Form for Hospitals

Facility identifying information

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

Facility name

Street address

City IL ZIP code

Project identifying information

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

Project name

IDPH Number

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

Total gross square footage of project area

Number of beds

Certificate of Need

Submit a copy of the approved certificate of need (CON).

CON project number Date approved

Is this a phased occupancy project? Yes No

Estimated project cost

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

Building Construction type per NFPA 220 for the existing building in which the renovation/remodel is occurring.

Number of stories Height in feet Year built

Sprinkler system Full Partial Dry Wet None

Fire pump capacity Water main size

Emergency power Generating set UPS

Fuel storage in gallons

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

UL assembly number / rating details

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

Number of stories Height in feet

Sprinkler system Full Partial Dry Wet None

Fire pump capacity Water main size

Emergency power Generating set UPS

Fuel storage capacity

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

Contact Information

Name of facility representative Title

Facility/Organization

Address

City State ZIP code

Phone number

E-mail address

Architectural firm

Address

City State ZIP code

Phone number

Name of architect of record for the project licensed in State of Illinois

E-mail address for architect of record Illinois license number

Sprinkler contractor

Address

City State ZIP code

Contact name Phone number

E-mail address Illinois State Fire Marshall license number

HVAC design firm

Address

City State ZIP code

Contact name Phone number

E-mail address

Electrical system designer

Address

City State ZIP code

Contact name Phone number

E-mail address

Fire alarm company

Address

City State ZIP code

Contact name Phone number

E-mail address

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.

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.

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.