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Infection Control Policy

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Infection Control Construction Permit

Infection Control Risk Assessment Matrix of Precautions for Construction & Renovation

Step One:

Using the following table, identify the Type of Construction Project Activity (Type A-D).

Type A - Inspection and Non-Invasive Activities

Includes, but is not limited to:

• removal of ceiling tiles for visual inspection limited to 1 tile per 50 square feet

• painting (but not sanding)

• wallcovering, electrical trim work, minor plumbing, and activities which do not generate dust or require cutting of walls or access to ceilings other than for visual inspection.

Type B - Small scale, short duration activities which create minimal dust

Includes, but is not limited to:

• installation of telephone and computer cabling

• access to chase spaces

• cutting of walls or ceiling where dust migration can be controlled.

Type C - Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies

Includes, but is not limited to:

• sanding of walls for painting or wall covering

• removal of floorcoverings, ceiling tiles and casework

• new wall construction

• minor duct work or electrical work above ceilings

• major cabling activities

• any activity which cannot be completed within a single workshift.

Type D - Major demolition and construction projects

Includes, but is not limited to:

• activities which require consecutive work shifts

• requires heavy demolition or removal of a complete cabling system

• new construction.

Step 1

Step Two:

Using the following table, identify the Patient Risk Groups that will be affected. If more than one risk group will be affected, select the higher risk group.

Low Risk

• Office areas

Medium Risk

• Cardiology

• Echocardiography

• Endoscopy

• Nuclear Medicine

• Physical Therapy

• Radiology/MRI

• Respiratory Therapy

High Risk

• CCU

• Emergency Room

• Labor & Delivery

• Laboratories (specimen)

• Newborn Nursery

• Outpatient Surgery

• Pediatrics

• Pharmacy

• Post Anesthesia Care Unit

• Surgical Units

Highest Risk

• Any area caring for immunocompromised patients

• Burn Unit

• Cardiac Cath Lab

• Central Sterile Supply

• Intensive Care Units

• Medical Unit

• Negative pressure isolation rooms

• Oncology

• Operating rooms including C-section rooms

Step 2

Step Three:

Match the patient risk group with the planned construction project type on the matrix to find the class of precautions or level of infection control activities required.

IC Matrix - Class of Precautions: Construction Project by Patient Risk

Class I-IV or Color-Coded Precautions are delineated on the following page.

Step 3

Step 4. Identify the areas surrounding the project area, assessing potential impact

Step 5. Identify specific site of activity eg, patient rooms, medication room, etc.

Step 6. Identify issues related to ventilation, plumbing, electrical in terms of the occurrence of probable outages.

Step 7. Identify containment measures, using prior assessment. What types of barriers? Will HEPA filtration be required?

Step 8. Consider potential risk of water damage. Is there a risk due to compromising structural integrity? (eg, wall, ceiling, roof)

Step 9. Work hours: Can or will the work be done during non-patient care hours?

Step 10. Do plans allow for adequate number of isolation/negative airflow rooms?

Yes No

Step 11. Do the plans allow for the required number & type of handwashing sinks?

Yes No

Step 12. Does the infection control staff agree with the minimum number of sinks for this project?

(Verify against AIA Guidelines for types and area)

Yes No

Step 13. Does the infection control staff agree with the plans relative to clean and soiled utility rooms?

Yes No

Step 14. Plan to discuss the following containment issues with the project team. Eg, traffic flow, housekeeping, debris removal (how and when),

Appendix: Identify and communicate the responsibility for project monitoring that includes infection control concerns and risks. The ICRA may be modified throughout the project. Revisions must be communicated to the Project Manager.

Infection Control Construction Permit

Construction Activity

Infection Control Risk Group

Construction Activity / Infection Control Precautions

Class I: Execute work by methods to minimize raising dust from construction operations. Immediately replace any ceiling tile displaced for visual inspection. Minor demolition for remodeling.

Class II: Provide active means to prevent airborne dust from dispersing into atmosphere. Water mist work surfaces to control dust while cutting. Seal unused doors with duct tape. Block off and seal air vents. Wipe surfaces with disinfectant. Contain construction waste before transport in tightly covered containers. Wet mop and/or vacuum with HEPA filtered vacuum before leaving work area. Place dust mat at entrance and exit of work area. Remove or isolate HVAC system in areas where work is being performed.

Class III: Obtain infection control permit before construction begins. Isolate HVAC system in area where work is being done to prevent contamination of the duct system. Complete all critical barriers or implement control cube method before construction begins. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. Do not remove barriers from work area until completed project is thoroughly cleaned by Environmental Services. Vacuum work with HEPA filtered vacuums. Wet mop with disinfectant. Remove barrier materials carefully to minimize spreading of dirt and debris. Contain construction waste before transport in tightly covered containers. Cover transport receptacles or carts. Tape covering. Remove or isolate HVAC system in areas where work is being performed.

Class IV: Obtain infection control permit before construction begins. Isolate HVAC system in area where work is being done to prevent contamination of duct system. Complete all critical barriers or implement control cube method before construction begins. Maintain negative air pressure within work site utilizing HEPA equipped air filtration units. Seal holes, pipes, conduits, and punctures appropriately. Construct anteroom and require all personnel to pass through this room so they can be vacuumed using a HEPA vacuum cleaner before leaving work site or they can wear cloth or paper coveralls that are removed each time they leave the work site. All personnel entering work site are required to wear shoe covers. Do not remove barriers from work area until completed project is thoroughly cleaned by the Environmental Service Dept. Vacuum work area with HEPA filtered vacuums. Wet mop with disinfectant. Remove barrier materials carefully to minimize spreading of dirt and debris associated with construction. Contain construction waste before transport in tightly covered containers. Cover transport receptacles or carts. Tape covering. Remove or isolate HVAC system in areas where work is being done.

Date:

Initials:

Permit Request By:

Permit Authorized By:

Date:

Date:

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What an Infection Control Policy Is and when it applies

An Infection Control Policy is a written organizational procedure that defines measures to prevent, detect, and respond to infectious disease risks in a workplace, facility, or service setting. It establishes scope, responsibilities, standard precautions, personal protective equipment (PPE) guidance, reporting and surveillance processes, training expectations, and review cycles. Many employers use this policy to meet regulatory obligations, reduce employee and client exposure, and document consistent practices for audits, inspections, and internal quality reviews.

Why a clear Infection Control Policy matters for compliance and safety

A concise, maintained policy reduces exposure risk, clarifies accountability, and creates an auditable record for regulators and insurers. It supports worker safety programs and helps meet industry-specific obligations.

Why a clear Infection Control Policy matters for compliance and safety

Who typically prepares and relies on the Infection Control Policy

Parties that review or sign the policy commonly include the infection control officer, the facility manager, HR, and executive leadership.

  • Healthcare and long-term care providers responsible for patient safety and HIPAA-related workflows.
  • Educational institutions managing students, staff, and campus public health measures.
  • Employers in essential services or manufacturing protecting on-site workers and visitors.

Primary roles involved in policy creation and sign-off

Infection Control Officer

Designated clinical or safety professional who drafts protocols, coordinates surveillance, and manages staff training. This person documents exposures, leads reviews, and acts as the primary liaison with public health authorities.

Facility Director

Operational leader who approves the policy, allocates resources for PPE and training, and ensures cross-departmental implementation and compliance with workplace safety and regulatory requirements.

Core elements to include in a professional Infection Control Policy

A robust policy should be clear, role-based, and measurable; include procedures for prevention, detection, and response; and define recordkeeping, training, and review timelines.

Scope

Define covered locations, populations, and activities. Specify whether the policy applies to employees, contractors, visitors, patients, or students and note any site-specific exclusions.

Roles & Duties

List responsible parties (infection control officer, supervisors, safety officer) with specific tasks for monitoring, reporting, training, and enforcement to avoid ambiguity in operations.

Standard Precautions

Describe hand hygiene, respiratory etiquette, environmental cleaning, waste handling, and engineering controls such as ventilation or physical distancing measures.

Personal Protective Equipment

Specify required PPE by task, donning/doffing procedures, reuse rules if any, storage, and procurement responsibilities to ensure consistent protection and supply management.

Surveillance & Reporting

Establish incident definitions, reporting channels, timelines for notification to public health, internal logging, and thresholds for escalation or operational changes.

Training & Audits

Outline mandatory training content, frequency, records retention, and how internal audits or drills will measure adherence and trigger corrective actions.

Required information and fields to capture in the policy document

Policy Title: Infection Control Policy
Effective Date: MM/DD/YYYY
Responsible Officer: Name and job title
Scope Statement: Locations and populations
Review Cycle: Annual or sooner
Signatures: Authorized signatories

Step-by-step: complete the Infection Control Policy

Follow these steps to prepare, approve, and distribute the policy with an auditable record and consistent version control.

  • 01
    Draft: Assemble required sections and assign responsibility for each.
  • 02
    Review: Circulate to clinical, legal, and HR reviewers for feedback.
  • 03
    Approve: Sign by authorized leadership and date the approval.
  • 04
    Distribute: Share the final document, track receipt, and archive the signed version.

How to configure an online workflow for completion and signatures

A standard online workflow reduces manual steps and creates an audit trail. Configure fields and authentication appropriate to your risk level.

Workflow Step Configuration
Upload Template PDF or DOCX with fillable fields
Place Fields Signature, date, text, and checkbox fields
Set Signers Assign roles and signing order
Authentication Email or stronger methods for sensitive records

Digital signing and eSubmission: platform capabilities to consider

Ensure the vendor can provide a business associate agreement for HIPAA-regulated data and export signed PDFs for long-term storage.

  • Audit Trail: Timestamp, IP, action history
  • Security: TLS in transit, AES-256 at rest
  • Integrations: Link to HR or records systems

Where to file, send, or submit the signed policy

Determine routing and retention destinations before distribution to ensure consistent storage and access for audits.

  • Internal Archive: Store signed copy in document management
  • HR Records: Add acknowledgement to personnel files
  • Safety Office: Deliver final policy to infection control team
  • Public Health: Report incidents as required by law

Timelines and review schedule to include in the policy

Set specific dates and deadlines for approval, training, incident reporting, and scheduled reviews to maintain currency and legal defensibility.

Policy Approval Deadline:

Complete review and sign-off within 30 days of draft completion

Staff Training Timeline:

Initial training within 14 days of policy release

Incident Reporting Window:

Report confirmed exposures within 24–72 hours as required

Annual Review:

Full policy review at least once every 12 months

Immediate Update:

Amend policy within 7 days of significant regulatory change

Key milestones and processing stages

Sequence the major milestones from drafting to archival to create a visible compliance trail.

01

Draft Completed

Policy text finalized and versioned for review

02

Cross-Functional Review

Clinical, legal, and operations feedback collected

03

Executive Approval

Leadership signs the final version

04

Distribution & Training

Policy shared and staff training scheduled

Common mistakes to avoid when preparing the policy

  • Using vague language on responsibilities that creates gaps in enforcement and accountability.
  • Failing to align PPE guidance with current public health guidance or supply realities.
  • Neglecting to document training attendance and competency verification for staff.
  • Not versioning the document or keeping an auditable history of prior policy editions.

Potential penalties and operational risks from an incomplete policy

Regulatory Fines: Civil penalties possible
License Risk: Suspension or restriction
HIPAA Exposure: Breach liability
OSHA Citations: Workplace safety fines
Litigation Exposure: Civil claims risk
Reputational Harm: Public trust damage

Industry examples of policy use and outcomes

Real-world examples illustrate how organizations apply infection control policies to achieve consistent operations and compliance.

Martin Properties — Facilities

Local property manager adopted an online policy for multi-site consistency

  • Rapid electronic distribution enabled immediate tenant notification
  • Tim Martin said the approach allowed processing and execution online with full compliance and efficient returns across mobile and desktop workflows.

Fertility Centers of Illinois — Healthcare

Healthcare practice formalized patient-facing protocols and staff training

  • Signed, tracked acknowledgements reduced follow-up administration
  • John Butler reported responsiveness from the platform team and smoother operations integrating signed forms into clinical workflows.

Comparison: signNow and competing eSignature options for executing policies

Compare vendor pricing and core capabilities relevant to signing and storing Infection Control Policies; verify plan specifics with each provider.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No

Practical tips for accurate and efficient completion

Apply these practical rules to reduce errors, speed approvals, and maintain a defensible record of policy adoption.

Use clear versioning and changelogs
Assign a version number and date to every policy revision and keep a changelog to show what changed and why.
Standardize signatures and authentication
Require consistent signer authentication and retain the audit trail to demonstrate signer intent and attribution.
Train staff on policy and documentation
Document training completion for each employee and test comprehension to reduce operational risk and show compliance.
Keep a single source of truth
Store the signed policy in a secure document repository with controlled access and regular backups.

Frequently asked questions about Infection Control Policy completion and signing

Answers to common questions about whether the policy can be e-signed, who must sign, and how to maintain compliance.


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