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WORKSHEETS FOR DETERMAINING EVACUATION …

Form CMS-2786M (07/2018) DEPARTMENT OF HEALTH AND HUMAN services CENTERS FOR medicare & medicaid services 2012 LIFE safety CODEForm Approved OMB Exempt WORKSHEETS FOR DETERMAINING EVACUATION CAPABILITY Intermediate Care Facilities for Individuals with Intellectual Disabilities (APPLICABLE TO EXISTING FACILITIES ONLY) (NFPA 101A, Guide on Alternative Approaches to Life safety 2013 Edition) Before completing these WORKSHEETS , read Chapter 6 of NFPA 101A, 2013 Edition, EVACUATION Capability Determination for Board and Care Occupancies. PART I WORKSHEETS FOR RATING RESIDENTS Complete WORKSHEETS , , and , and determine the EVACUATION Assistance Score for each resident in the COVER SHEET FOR RATING THE RESIDENTS ZONE OF ZONES NAME OF FACILITY ADDRESS OF FACILITY ZONE(S) EVALUATED PROVIDER/VENDOR NO.

2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt PART II – WORKSHEETS FOR CALCULATING THE EVACUATION CAPABILITY SCORE (E-Score) Complete Worksheets 6.8.4 through 6.8.11 for each facility or zone. Complete Worksheet 6.8.4 and determine the Total Evacuation Assistance Score

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