Capital Development Guideline - Department of Health ... FRM Policy...2.0 The Guidelines and their...

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 i

Capital Development Guideline 71 Fire risk management policy and procedures Department of Human Services Capital Management Branch 2008

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 ii

Acknowledgments

copy Copyright State of Victoria 2008

Published by the Capital Management Branch Financial and Corporate Services Division Victorian Government Department of Human Services

This publication is available at Department of Human Services Internet address wwwcapitaldhsvicgovauTechnicalGuidelinesFireRiskManagement

Disclaimer

The purpose of these fire risk management guidelines is to provide appropriate levels of fire safety for occupants of a building subject to these Guidelines by enabling appropriately qualified professional advisers such as registered fire safety engineers and building surveyors to

bull audit and assess fire risk

bull recommend steps to minimise fire risk

bull assess and report on acceptable standards of fire safety

in specific settings

The use of the Guidelines is subject to the following

a) The Guidelines do not constitute all of the possible fire safety matters that may apply to a specific situation but are provided for assistance in determining appropriate fire safety measures It is up to individuals acting with appropriate professional advice to determine their application to particular situations

b) Guidelines 73 to 710 must be used for purposes only within the range set out in the lsquoIntroductionrsquo section at the start of each document

c) In addition to the fire safety requirements and standards in the Guidelines owners occupiers and operators of facilities may be subject to various other statutory common law and contractual obligations They must seek advice including legal advice on the existence and scope of these obligations

The Department of Human Services and organisationsindividuals involved in the preparation of these documents make no representation that the Guidelines are suitable for any particular situation and accept no responsibility for any loss or damage arising out of any decision to apply the Guidelines to any particular situation

Definitions

Defined terms are in italics when first used in each guideline A list of all definitions can be found in Appendix 1 of Guideline 71

Contents Contents iii

10 The Department of Human Services fire risk management goals and objectives 1

20 The Guidelines and their purpose 3

21 Reasons to consider more than the legislative requirements 3

22 Changes from the previous edition of the Guidelines 4

23 The fire risk management guideline structure 5

30 Legislative requirements for buildings with sleeping accommodation in Victoria7

31 The Guidelines and the BCA classification system 7

32 Mandatory requirements for sleeping accommodation 8

33 New buildings 9

34 Retrospective requirements for existing buildings 9

35 Change of use of a building 9

36 Building andor occupancy permits 9

37 Maintenance of essential safety measures 9

40 Determining guideline applicability and requirements10

41 Buildings to which these Guidelines apply 10

42 Parts of a building subject to these Guidelines but used for other purposes 10

43 Adjoining buildings 10

44 Connected buildings 10

45 Requirements for a building subject to these Guidelines 11

46 The key steps in determining if these Guidelines are applicable 11

47 When the Guidelines do not apply 14

50 The fire risk management process15

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 iii

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 iv

51 Exceptions to the fire safety audit and fire risk assessment process 16

52 Temporary occupation of buildings 17

60 Management responsibilities19

61 Fire safety policies and programs for fire precautions 19

62 Nominated fire risk management responsibilities 20

63 General duties and responsibilities of all staff 21

64 Expectations of tenants in Housing amp Community Building rental properties 21

65 Reporting of fires 22

70 Maintenance and testing23

Appendix 1 Definitions used in these Guidelines 24

Appendix 2 Using the occupant risk matrix30

A21 Determining occupant profile 30

A22 Determining staff profile 30

A23 Assessing the results of the occupant risk matrix 30

Appendix 3 Fire Safety Certificate ndash 71 and the Essential Safety Measures Report 32

Appendix 4 Approval process for implementation of fire risk management projects 37

Summary Department of Human Services management and operational arrangements 37

Appendix 5 Recommended line of reporting roles and responsibilities 38

Divisional Director 38

CMB Responsibility 38

Programs 38

Regional Fire Risk Management Coordinator 38

Responsibility at buildingsiteservice 38

Appendix 6 Fire risk management mdash incident reporting39

10 The Department of Human Services fire risk management goals and objectives

The Department of Human Services is committed to ensure that the people of Victoria have access to services that protect and enhance their health and social wellbeing and to best allocate available resources to meet their needs

As part of this commitment the Department needs to address fire risk management that is consistent with satisfying its responsibilities in the most cost-effective manner

The goal of the Department of Human Services is therefore to meet as a minimum the standard of fire safety applicable to the general community and to meet additional standards where appropriate for a particular client tenant or occupant group

The Department of Human Services recognises that the risk to life from fire can be significantly greater where its clients are asleep in a building or need assistance to evacuate from a building

Objectives

The fire risk management objectives of the Department can be divided into primary objectives and supplementary objectives

The primary objectives are

bull to safeguard from illness or injury due to a fire the people resorting to a building subject to these Guidelines

bull to comply with relevant acts and regulations that relate to fire safety in buildings that are

o owned andor operated by Department of Human Services the Housing amp Community Building (HampCB) or a community service organisation for the purpose of providing client bed-based care support or supervision services that are either directly delivered or funded by Department of Human Services through a service agreement

or

o owned andor operated by Department of Human Services or HampCB and provide sleeping accommodation for occupants

To satisfy the objective of safeguarding occupants from illness or injury due to a fire in nominated buildings the Department of Human Services requires

bull a fire safety auditrisk assessment to be undertaken every 10 years with a review of the report after 5 years within the 10 year cycle to confirm that the fire safety strategy is being satisfied This requirement is for facilities where Guideline 73 75 76 79 or 710 applies

bull a fire safety compliance check to be undertaken every 5 years instead of the above fire safety auditrisk assessment because the smaller domestic scale of the facilities permits the use of a specifically developed compliance check instrument rather than a more detailed fire safety auditrisk assessment This requirement is typically suitable for facilities where Guideline 74 or 77 applies

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 1

The resulting reports are to identify fire hazards and determine workable precautions to address the hazards so that fire safety upgrades can be implemented in accordance with the recommendations of the report

The supplementary objectives are

bull to maintain services to the local communities

bull to enable continuation of operations (minimisation of business interruption)

bull to protect assets

bull to achieve community expectations for service levels and standards

bull to provide a safe and secure environment for the persons resorting to the facility (for example in secure facilities)

A judgement at the senior management level is required as to the relative importance of a building or part of a building in order to determine if there is a need for additional precautions to satisfy these supplementary objectives


20 The Guidelines and their purpose This guideline and others that make up the Capital Development Guidelines Series 7 ndash Fire Risk Management provide a general indication of the Departmentrsquos expectations with respect to fire risk management in nominated facilities from which it provides and receives client services

The Series 7 serves the purposes of

1 assisting in determining appropriate levels of fire safety in buildings that are owned andor operated by Department of Human Services HampCB or a community service organisation for the purpose of providing bed-based care support or supervision services that are either directly delivered or funded by Department of Human Services through a service agreement (Guidelines 73 74 75 76 and 77)

2 affording adequate life safety consideration in buildings that Department of Human Services or HampCB owns that provide sleeping accommodation Specifically for Housing amp Community Building these buildings are single dwellings multi-storey apartments and boarding houses (Guidelines 78 79 and 710)

These purposes are achieved by applying the fire risk management process the process of determining by a fire safety compliance check or fire risk assessment fire safety audits and fire safety re-audits whether an appropriate level of fire safety is achieved in a building

An appropriate level of fire safety means not only the minimum statutory requirements applicable but also the consideration of challenging factors relevant to service needs security occupant profile and behaviour staff profile fire prevention training and ongoing maintenance

A fire safety compliance check may be undertaken instead of a building specific fire risk assessment where the compliance check has been derived from the prescriptive requirements of the relevant Guideline for Supported Community Based Houses (74) and Community Based Houses (77)

For dwellings managed by Housing amp Community Building (Guidelines 78 79 and 710) a specifically designed safety inspection regime has been established by Housing amp Community Building for its public housing properties

21 Reasons to consider more than the legislative requirements The DHS as an employer has obligations for duty of care under legislation such as the Occupational Health amp Safety Act 1985 that require employers so far as is practicable to maintain a working environment that is safe and without risks to health

The Act defines lsquopracticablersquo as practicable having regard to bull The severity of the hazard or risk in question

bull The state of knowledge about that hazard or risk and any ways of mitigating that hazard or risk

bull The availability and suitability of ways to remove or mitigate that hazard or risk

bull The cost of removing or mitigating that hazard or risk

To fulfil these obligations in relation to fire the Department of Human Services must be able to show that it has assessed the risk of fire and so far as is practicable taken steps to minimise those


risks to health and safety

The provision of care by DHS for the population of Victoria in an evolving and changing environment in particular the greater provision of community-based services has exposed limitations in the building regulations and the prescriptive deemed-to-satisfy provisions of the Building Code of Australia (BCA) especially the classification system which can lead to the provision of inadequate or inappropriate fire precautions

The building regulations prescribe the inclusion of fire safety requirements to a broad use of buildings and represent a minimum standard that the community is prepared to accept In so doing the building regulations provide a generalised response to reducing the risk of loss of life property and injuries The building regulations do not usually prescribe to matters that relate to specific occupant needs and interactions staffing levels or training

The Department of Human Services has a primary responsibility to occupants in buildings from which it provides services Therefore many appropriate fire safety responses might be outside the scope of the building regulations and some buildings or service models may also be outside the range of buildings currently considered by the building regulations

The Guidelines are intended to address these differences and to consider individual occupant safety as the prime objective

Examples of the additional requirements in the Guidelines include enhancement or addition of passive and active fire safety systems staff training fire exercises case management of occupants reporting responsibilities and fire prevention

22 Changes from the previous edition of the Guidelines This new edition of the Guidelines has been amended from the second edition (2001) of the original (1997) edition of the Guidelines The specific changes are

bull clarification that the Guidelines apply only to facilities where occupants are provided with bed-based care support or supervision facilities that Department of Human Services owns that provide sleeping accommodation or buildings attached or connected to those and not adequately fire separated (now defined in the Guidelines as buildings subject to these Guidelines)

bull an increase of the maximum floor area for a supported community-based house from 350 square metres to 500 square metres to reflect improved amenity and design criteria which has increased overall room sizes

bull increase of the maximum number of occupants in a new supported community-based house (Guideline 74) from 6 to 8 occupants to reflect changed service delivery and staffing models

bull clarification and change in the audit frequency to require an initial fire safety audit (or desktop audit) with fire safety audit review at 5 years a complete new audit at 10 years and essential safety measures reports annually The previous audit period was every three years and did not include the annual essential safety measures audit

bull clarification and confirmation that a fire safety compliance check can be done instead of a fire safety audit or re-audit for buildings subject to Guidelines 74 and 77

bull confirmation that for Guideline 78 the requirements will be derived from a review of the



building using the BCA as a benchmark The requirements in the Guideline 78 enhance the assessment of the building by considering client needs

bull revision of the requirements for non-combustibility and fire hazard properties of materials based on changes to the BCA

bull clarification review and introduction of requirements in AS3959 (Building in Bushfire-prone Areas) and requirements for a fire risk assessment for bushfire protection management and evacuation strategies for all Department of Human Services owned operated or funded buildings that are located in a bushfire prone area (as defined in the BCA) or a wildfire management overlay (as defined in any planning scheme)

bull renaming of the fire safety plan to fire safety handbook (to overcome confusion around the misunderstanding that a fire safety plan referred to a drawing) and additional text to reinforce the necessity and importance of this document in implementation of the fire safety strategy and these Guidelines

bull editorial changes to reflect changes in numbering and description of technical documents standards codes etc

bull deletion of technical provisions that are now adequately covered in legislation

bull consistency in the Guidelines with new legislative requirements particularly for installation of fire sprinklers mains powered smoke alarms and maintenance of essential safety measures

bull rationalisation of requirements of the Guidelines which were inconsistent with existing departmental procedures (where the existing procedures were at least as acceptable as the guideline requirements including replacement of fire safety compliance checks for dwellings with existing HampCB safety checks)

23 The fire risk management guideline structure The fire risk management process includes use of appropriate engineering technical and management tools including Australian Standard(AS)-4360 Risk Management AS-4655 Fire Safety Audits The International Fire Engineering Guidelines (IFEG) and the Department of Human Services Fire and Emergency Response Procedures and Training Framework1 The specific Guideline structure is described in Flowchart 2 on the next page Further details are included in Guideline 72

1 Available at httpwwwdhsvicgovaucapdevemergprochtm


30 Legislative requirements for buildings with sleeping accommodation in Victoria

The following information is provided to assist in determining appropriate requirements for fire safety for occupants of all buildings including occupants of buildings subject to these Guidelines To determine the particular legislative requirements and required permits for any specific case the advice of a registered building surveyor2 must be sought

31 The Guidelines and the BCA classification system The Building Act provides for the regulation of building and building standards and key objectives of the regulations that are relevant to the Departmental Guidelines on fire risk management are

bull the prescribed standards for the construction and demolition of buildings bull the regulation of matters relating to the use and maintenance of buildings and bull the prescribed standards and matters relating to the maintenance of fire safety and safety

measures

The regulations apply measures that are determined on the basis of the use of the building through the uniform technical provisions of the Building Code of Australia (BCA) for a Class of occupancy

The following provides typical Class of occupancy listed in the BCA that may be relevant to a specific FRM Guideline

Capital Development Guideline

Fire Risk Management

Building Code of Australia

Classification 71 Not applicable 72 Not applicable

73 Secure Facilities Class 3 Occupancy -sub-group (f) a residential part of a detention centre

74 Supported Community-Based Houses

Class 1a Occupancy Class 1b Occupancy Class 3 Occupancy Class 9a Occupancy - a health care building (b) Class 9c Occupancy ndash an aged care building

(-see below the table for descriptions)75 Congregate Care

Facilities Class 3 Occupancy Class 9a Occupancy - a health care building (b) Class 9c Occupancy ndash an aged care building

(-see below the table for descriptions)76 Hospitals Class 3 Occupancy ndash a residential building of sub-group

(a) (d) or (f) Class 9a Occupancy ndash a health-care building Class 9c Occupancy ndash an aged care building

77 Community-Based Houses

Class 1a Occupancy Class 1b Occupancy

2 Building Surveyors are registered by the Building Practitioners Board and are employed in Local Government or private practice

Further details are available at httpwwwbuildingcommissioncomauwwwhtml256-finding-a-registered-building-practitionerasp


Class 3 Occupancy (-see below the table for descriptions)

78 Single dwellings Class 1a Occupancy ndash a single dwelling being a detached house or one of a group of two or more attached dwellings each being a building separated by a fire-resisting wall

79 Multi-Storey Housing Class 2 Occupancy ndash a building containing 2 or more sole-occupancy units each being a separate dwelling

710 Boarding Houses Class 1b Occupancy Class 3 Occupancy -sub-group (a)

(-see below the table for descriptions)

Class 1a Occupancy ndash a single dwelling being a detached house or one of a group of two or more attached dwellings each being a building separated by a fire-resisting wall

Class 1b Occupancy mdash a boarding house guest house hostel or the like not exceeding 300 m2 in total area of floors measured over the enclosing walls

Class 2 Occupancy ndash a building containing 2 or more sole-occupancy units each being a separate dwelling

Class 3 Occupancymdash a residential building other than a building of Class 1 which is a common place of long term or transient living for a number of unrelated persons including

(a) a boarding-house guest house hostel lodging-house or backpackers accommodation (d) accommodation for the aged children or people with disabilities (f) a residential part of a detention centre

Class 9a Occupancy ndash a health-care building means a building whose occupants or patients undergo medical treatment generally need physical assistance to evacuate the building during an emergency and include-

(a) a public or private hospital or (b) a nursing home or similar facility for sick or disabled persons needing full-time care or (c) a clinic day surgery or procedure unit where the affects of the predominate treatment

administered involves patients becoming non-ambulatory and requiring supervised medical care on the premises for some time after the treatment

Class 9c Occupancy ndash an aged care building mans a building for building for residential accommodation of aged persons who due to varying degrees of incapacity associated with the ageing process are provided with personal care services and 24 hour staff assistance to evacuate the building during an emergency

32 Mandatory requirements for sleeping accommodation3 All buildings with sleeping accommodation in Victoria are required to have at least one battery-powered smoke alarm outside a bedroom door This applies regardless of the age type location or size of the building For newer or larger buildings or buildings providing care services the requirements increase Mains powered (240 volt) smoke alarms with battery backup smoke detectors and automatic fire sprinklers may be required

3 See the specific provisions of the Building Regulations available at httpwwwdmsdpcvicgovau for more detail


33 New buildings New buildings must comply with the requirements of the Building Code of Australia4 (BCA) which includes specific fire safety provisions Most new buildings with sleeping accommodation and provision of care services require automatic fire sprinklers and mains powered (240 volt) with battery backup smoke alarms Additional construction requirements and limits on use of certain materials also apply

34 Retrospective requirements for existing buildings The building regulations include provisions for retrospective installation of mains powered (240 volt) with battery backup smoke alarms and automatic fire sprinklers in certain residential buildings These provisions apply even if the building has been used for the same purpose in the past and no change of use or building work is proposed

Further details are available at httpwwwbuildingcommissioncomauwwwhtml139-introductionasp

35 Change of use of a building Based on consultation and advice to the Divisions or Regions the Department may engage a building surveyor to determine if a change of use to a building has occurred

If a building is to be converted to a new use (or new classification) then compliance with the regulations will apply5 though the building surveyor may exempt a building from compliance with any of these regulations applicable to the new use

A relevant example of a change of use would be the purchase of an existing Class 1a single dwelling for use as a Class 3 residential building accommodating persons with a disability This will require an analysis and review by a building surveyor to determine the appropriate requirements6 and to issue a building permit and new occupancy permit

36 Building andor occupancy permits All new buildings alterations or additions to existing buildings or change of use require the issue of a building permit under the building regulations

For new buildings and in cases of the change of use or substantial alterations to existing buildings an occupancy permit is also required

37 Maintenance of essential safety measures All buildings other than Class 1 (a single dwelling) and Class 10 require essential safety measures to be maintained and verified on at least an annual basis Examples of essential safety measures are smoke alarms sprinklers exits and exit doors and floor and wall linings Further details and a copy of the required annual essential safety measures report form are included in Appendix 3 or are available at httpwwwbuildingcommissioncomauwwwhtml1176-building-formsasp

4 Further details available at httpwwwabcbgovau 5 A building surveyor appointed for the change of use has some discretion to vary these requirements in certain circumstances 6 If these Guidelines also apply a risk assessment may also need to be undertaken by a registered fire safety engineer


40 Determining guideline applicability and requirements 41 Buildings to which these Guidelines apply These Guidelines apply to

1 buildings that are owned andor operated by Department of Human Services HampCB or a community service organisation for the purpose of providing bed-based care support or supervision services that are either directly delivered or funded by Department of Human Services through a service agreement (Guidelines 73 74 75 76 and 77)

or

2 buildings that Department of Human Services or HampCB owns that provide sleeping accommodation Specifically for Housing amp Community Building these buildings are dwellings multi-storey apartments and boarding houses (Guidelines 78 79 and 710)

42 Parts of a building subject to these Guidelines but used for other purposes Where part of a building is used for a purpose other than sleeping accommodation or bed-based care support or supervision that part of the building must also comply with these Guidelines including requirements for audits and fire risk assessments as applicable This is because these spaces can contribute to the overall fire risk in the building and they contain common services and equipment These spaces must be considered in any evacuation procedures

43 Adjoining buildings Building used for a purpose other than sleeping accommodation or bed-based care support or supervision that exist on the same site need not be considered as buildings subject to these Guidelines if the separation distances and external wall construction of both buildings satisfy the relevant performance provisions of the BCA For most situations to satisfy the BCA this may require a separation distance of up to 18 metres between Class 1 buildings and up to 6 metres for other classifications unless walls are fire resisting and all openings are adequately protected

Where there is an inadequate separation from a building not subject to these Guidelines then that building must be considered in terms of the threat of fire spread to any building subject to these Guidelines

Single dwellings on the same allotment generally require to be separated by up to 18 metres or require external walls to be fire-resisting

44 Connected buildings Where other buildings exist on a site and are only connected by covered walkways carports or similar these can be considered as separate buildings Therefore they are not subject to a quantitative assessment if

bull the buildings satisfy Section 43 above and the connection is of single storey construction

bull they are constructed entirely of non-combustible materials



bull they are either substantially open or adequately smoke andor fire separated at the connection

45 Requirements for a building subject to these Guidelines If the Guidelines apply to a facility then the procedures in Guidelines 71 and 72 must be followed and the specific building and occupant outcomes in the relevant Guidelines 73 74 75 76 77 78 79 or 710 must be applied

46 The key steps in determining if these Guidelines are applicable The following are the two steps for determining if these Guidelines apply to a facility

Step 1 Establishing if the Series 7 Fire Safety Management Guidelines apply to a selected situation

The applicability of these Guidelines can be determined in a number of ways In all cases the facility must be either

1 owned andor operated by Department of Human Services HampCB or a community service organisation for the purpose of providing bed-based care support or supervision services that are either directly delivered or funded by Department of Human Services through a service agreement

or

2 a facility that Department of Human Services or HampCB owns that provides sleeping accommodation but staff are not provided at all times that occupants are present (that is single dwellings multi-storey apartments and boarding houses)

Further details are shown in Flowchart 1 A process for assisting in determining guideline applicability or appropriate fire safety standards for buildings not subject to these Guidelines is included in Appendix 2

Where a facility provides a service that is subject to a service agreement with Department of Human Services there are five (5) lsquofire safety standardsrsquo described in the service agreements with providers for bed-based services dependent on the type of building and the relationship with the Department of Human Services Two of the Fire Safety Standards require compliance with these Guidelines (Fire Safety Standards No 4 and No 5) The Fire Safety Standards also include annual fire safety certificates and other reporting requirements

Further details are available at httpwwwdhsvicgovausrvc_agmntchpt5htmtoptop

Flowchart 1


Step 2 Determining which Guideline applies and the BCA assessment criteria

Once it is established that the facility is subject to these Guidelines the occupant and staff profiles need to be confirmed as this is critical information for interpreting and applying the specific guideline The two other key assessment criteria are BCA classification by the building surveyor and determination of sole-occupancy unit7 (SOU) as these have implications for applying the BCA particularly in relation to the requirements for bedrooms (occupant profiles and staff profiles are defined in Appendix 1 of this Guideline) Further confirmation of specific guideline applicability can be confirmed by reviewing the process in Appendix 2

Guideline applicability can also be determined from the specific guideline title The following table includes Guideline descriptions relevant staff and occupant profiles the possible BCA classification that is likely to be determined by the building surveyor and the possible sole-occupancy unit criteria

Table 1

Guideline Title Staff Profile Typical Occupant Profile

Possible BCA Classification

Application of sole-occupancy unit (SOU) definition

71 Policy and procedures

na na na na

72 Fire risk management engineering guidelines

na na na na

73 Secure facilities Type 3 or Type 4

Ambulant Type 2 to non-ambulant Type 4

Class1b (if less than 300 m2) Class 3

Each occupant bedroom (or suite of rooms) is one SOU

74 Supported community-based Houses

Type 3 Ambulant Type 2 to non-ambulant Type 5

Class1b (if less than 300 m2) Class 3 Class 9a or Class 9c

The building is a single dwelling

75 Congregate care facilities



The building is a single dwelling or each occupant bedroom (or suite of rooms) is one SOU

76 Hospitals Type 4 All occupant profiles

Class 9a Each occupant bedroom (or suite of rooms) is one SOU

7 The BCA defines a sole-occupancy unit as lsquoa room or other part of a building for occupation by one or joint owner lessee tenant

or other occupier to the exclusion of any other owner lessee tenant or other occupier and includes (a) a dwelling or (b) a room or suite of rooms in a Class 3 building which includes sleeping facilities or (c) a room or suite of associated rooms in a Class 5 6 7 8 or 9 building or (d) a room or suite of associated rooms in a Class 9c aged care building which includes sleeping facilities and any area for the exclusive use of a residentrsquo


Table 1




77 Community-based houses

Type 3 Ambulant Type 1 to ambulant Type 28



78 Single dwellings Type 1 Ambulant Type 19 Class 1a Class1b (if less than 300 m2)


79 Multi-storey housing

Type 1 Ambulant Type 19 Class 2 Each separate dwelling is one SOU

710 Boarding houses Type 1 Ambulant Type 19 Class 1b (if less than 300 m2) or Class 3


47 When the Guidelines do not apply Where these Guidelines do not apply the Department of Human Services has the expectation that building owners or operators will comply with all statutory obligations in relation to fire safety including the completion of an Annual Essential Safety Measures Report in accordance with Part 12 of the Building Regulations

8 One resident of occupant profile non-ambulant Type 4 or 5 is also allowed All the remaining (up to) 11 residents must be occupant

profile ambulant Type 1 or 2 9 Assumes at least one ambulant Type 1 occupant in a dwelling or SOU for example young children and other persons under the

care or supervision of an ambulant Type 1 occupant in a family environment might not be ambulant Type 1 but are considered under the parental control and responsibility of that primary carer


50 The fire risk management process The fire risk management process is defined as the process of determining by fire safety compliance check or fire safety audits fire safety re-audits and fire risk assessments whether an appropriate level of fire safety (the agreed fire safety strategy) is achieved in a building

In these Guidelines the objectives of a fire risk assessment are to satisfy the relevant performance requirements of the BCA for all buildings regardless of age and to include any additional supplementary objectives which may apply (see Section 1 of these Guidelines)

The management of the cyclic process includes these stages

Stage 1 Undertake a building fire safety compliance check or fire safety audit10 for existing buildings or a desktop fire safety audit for proposed new buildings

Note For most buildings the audit objectives will be to determine compliance with the relevant fire safety provisions of the Deemed-to-Satisfy (DtS) Provisions of the BCA The audit criteria will be to satisfy the relevant fire safety Performance Requirements of the BCA and these Guidelines

Stage 2 For facilities that may be covered under 73 75 76 79 and 710 undertake the appropriate fire risk assessment11 to develop a fire safety strategy and assess the audit findings against the fire safety strategy Where the audit findings indicate variations from the relevant fire safety provisions of the Deemed-to-Satisfy (DtS) Provisions of the BCA the fire risk assessment process in accordance with the methodology in the IFEG can be used to determine whether any further measures are necessary

Note The fire safety strategy will be to comply with these guidelines (including the relevant performance requirements of the BCA and any supplementary objectives) and the fire risk assessment will include outcomes that may require work to be undertaken or systems to be installed training to be implemented and recommendations for ongoing maintenance verification and management of the fire safety systems and staff and occupant profiles Even if the building completely complies with the Deemed-to-Satisfy (DtS) Provisions of the BCA a fire risk assessment must be undertaken to address all fire safety matters

Stage 3 Approval of the fire safety compliance check report or fire safety strategy and Fire Engineering Report (FER) outcomes

Stage 4 Preparation of a fire safety handbook11 for facilities covered under 73 75 76 79 and 710 The fire safety handbook is to document the fire safety strategy developed in the fire risk assessment

Stage 5 Implementation of the program of work training and maintenance (including annual essential safety measures and Department of Human Services reporting requirements)

10 Undertaken by a competent person see Guideline72 for further details 11 Undertaken by a competent person see Guideline72 for further details


Stage 6 Undertake a fire safety compliance check or re-audit (after no more than 5 years) to confirm the original fire safety strategy is being satisfied

Note The audit and re-audit process confirms the fire safety strategy to support life safety planning and budgeting on a five year rolling basis The audit criteria will be to satisfy the fire safety strategy documented in the fire safety handbook (that is the purpose of a re-audit is to confirm the original fire safety strategy is being satisfied) It is not usually the intention or outcome of a re-audit that existing fire safety systems be replaced or updated only because they may have become superseded by amendments to the relevant fire safety provisions of the DtS provisions of the BCA since the original audit Where those regulatory changes have occurred they must be considered as part of a fire risk assessment

Stage 7 Implementation of the program of work training and maintenance that may have resulted from the fire safety compliance check or re-audit

Note Where a building has not substantially been altered or changed since the original audit it is not expected that these works (if any) would be significant

Stage 8 A new fire safety compliance check or fire safety audit for the building after no more than 10 years

Note For most buildings the audit objectives will be to determine compliance with the relevant fire safety provisions of the Deemed-to-Satisfy (DtS) Provisions of the BCA and the audit criteria will be to satisfy the relevant fire safety Performance Requirements of the BCA and these Guidelines current at that time Where these have not changed significantly in the previous 10 year period the new fire safety strategy may not be significantly different to the original

51 Exceptions to the fire safety audit and fire risk assessment process The Department of Human Services has recognised the practical economic and physical limitations of undertaking a fire safety audit and fire risk assessment of every facility subject to these Guidelines Therefore some specific Guidelines for groups of similar buildings have been produced The details of these are in Table 2 as follows

Table 2 Application of the fire risk management process

Department of Human Services Guideline number

Application Fire safety compliance check or Fire safety audit required and time period

Fire safety compliance check or Fire safety re-audit required and time period

Fire risk assessment required

71 Policy and procedures na na na


na na na

73 Secure facilities Yes at commencement of operation and not more than 10 years

Yes at the halfway period between audits not more than 5 years

Yes3

74 Supported community-based houses

Yes1 a fire safety compliance check at commencement of operation and every 5 years

Yes1 a fire safety compliance check not more than 5 years

No unless compliance with the Guideline 74 prescriptive requirements cannot be met








Yes at commencement of operation and not more than 10 years


Yes3

76 Hospitals Yes at commencement of operation and not more than 10 years


Yes3





78 Single dwellings Safety Inspections2 to Guideline 78 14

Safety Inspections2 to Guideline 78 14

No4

79 Multi-storey housing Safety Inspections2 to Guideline 79 22


No4

710 Boarding houses Safety Inspections2 to Guideline 710 23


No4

Note 1 A Fire Safety Compliance Check can be undertaken by an appropriately qualified person (eg fire safety engineer or building surveyor who has undergone familiarisation of the Capital Development Series 7 Guidelines ndash Fire Risk Management) instead of a fire safety audit or re-audit as the guideline forms the prescriptive outcomes of a generic fire risk assessment If these prescriptive outcomes cannot be complied with in their entirety then a fire safety audit and fire risk assessment must be undertaken by a fire safety engineer

Note 2 The fire safety audit process is managed by Housing amp Community Building and the relevant Division in the Department of Human Services and the process is satisfied by established procedures involving Safety Inspections at specified times and at periodic intervals See Guideline 78 79 and 710 for details of the inspection regime

Note 3 Even if compliance with the legislative requirements of the Building Act Building Regulations and the Building Code of Australia are satisfied a fire risk assessment is required to be undertaken by a fire safety engineer to ensure that all fire risks specific to that building have been considered and are incorporated into the fire safety strategy and a fire safety handbook is produced for the operator of the building

Note 4 Guideline 78 79 and 710 includes the prescriptive outcomes of a generic fire risk assessment Compliance with the Guideline therefore satisfies the requirement for a fire risk assessment

52 Temporary occupation of buildings Occasionally it is necessary to house occupants on a temporary basis while more permanent accommodation is being sourced The cause may be due to rebuilding of facilities temporary undersupply of facilities or short-term unusual circumstances In these situations occupant fire safety must be maintained and compliance with these Guidelines is still required

The Department of Human Services Disability Services Division has prepared a short-term accommodation model which may be suitable for addressing temporary accommodation12 It may 12 Contact Department of Human Services Capital Management Branch for further details Usually temporary occupation would not

exceed 6 months in duration



also be beneficial to undertake a fire risk assessment to establish cost-effective fire safety solutions particularly if the temporary building use would otherwise require installation of relatively expensive fire safety systems such as fire sprinklers or fire rated construction

A building surveyorrsquos advice must be sought to determine if the fire risk assessment may demonstrate compliance with the BCA but without installation of mandatory Guideline systems such as sprinklers or smoke walls (for example by requiring extra or improved staff profiles or staffing numbers) The approval process may also include determination by the Building Appeals Board13 that the design satisfies the BCA

The occupant risk matrix in Appendix 2 can also be used in these situations to determine whether changed staff profiles or increased fire safety systems are the most suitable solution It must be noted that the building regulations do not consider temporary buildings and therefore all relevant building and occupant permits must still be obtained

13 Further details can be found at httpwwwbuildingcommissioncomauwwwhtml531-what-you-need-to-know-about-the-babasp

60 Management responsibilities Chief executives and general managers of services agencies networks and other facilities are responsible for ensuring the implementation of appropriate fire risk management measures required to satisfy statutory requirements and the appropriate Department of Human Services guidelines

The form in Appendix 3 includes management responsibilities for annual reporting of fire safety with the annual essential safety measures report form required by the building regulations

Recommended reporting structures and processes are included in Appendices 4 5 and 6 Minor modifications can be made to suit the management structure of the department provided a clear line of responsibility is defined

In addition to ensuring that all statutory requirements and guidelines are observed chief executives and general managers must have appropriate fire safety policies and programs of work for maintaining monitoring and if appropriate improving fire risk management at their premises

For Housing amp Community Building (HampCB) rental accommodation housing occupants with evacuation capabilities typical of the general population it is expected that the occupants will take some responsibility for their own fire safety The expected responsibilities of tenants will be defined in the appropriate OoH guideline

61 Fire safety policies and programs for fire precautions Each Department of Human Services building or Department-funded building or group of buildings must have

bull a fire safety handbook for facilities covered under 73 75 76 79 and 710

bull a program (established after an inspection or fire safety audit and if required a fire risk assessment) for installing and satisfactorily maintaining an adequate level of physical and fire safety management measures designed to prevent the occurrence of fire as far as practicable If fire does occur measures must be provided for its early detection and warning and to control and stop the spread of fire Records must be retained of maintenance undertaken

bull an Emergency Control Organisation (not including HampCB properties) and emergency procedures as required by the relevant Guideline to address means for raising the alarm in case of fire methods for the movement or evacuation of occupants in an emergency means of fire-fighting and appropriate periodic and formally recorded staff training in all these matters

bull client management plans that identify occupants with the potential for exhibiting fire lighting behaviour and other fire related risks including the potential to inflict self harm For HampCB properties reference is also to be made to the PSAM Emergency Unit These management plans must be made available to all relevant staff and appropriate precautions implemented

Fire safety strategies including fire precautions programs and evacuation plans must not remain static These policies programs and plans need to be reviewed regularly (at least yearly) to take account of changes in the structure of buildings their functions occupants and contents and any other matters which may have a bearing on fire safety

The Secretary of the Department of Human Services has overall responsibility for fire safety within the portfolio To assist them they must appoint a senior staff member(s) andor establish and


Emergency Planning Committee(s) that will have responsibility for fire safety matters However CEOs and managers of networks agencies and other facilities and buildings all have responsibilities for fire safety They must ensure an ongoing commitment to satisfying the requirements of all relevant regulations and the Department Guidelines for fire risk management They must also ensure that where appropriate programs of investment in fire precautions are properly accounted for in the business plans for their areas of responsibility

62 Nominated fire risk management responsibilities For general building stock not managed by HampCB each facility or group of buildings must have a nominated member of staff or Emergency Control Organisation and Emergency Planning Committee that is assigned with the fire risk management responsibilities

External fire safety advisers and consultants must not be appointed as nominated fire risk management officers

Responsibilities include

bull supervision of the effective upkeep of the fire safety management provisions established for the premises as appropriate

bull ensuring that all facility staff regularly participate in fire safety training and fire safety exercise (this requirement does not apply to HampCB rental general stock)

bull ensuring regular fire safety exercises are conducted (this requirement does not apply to dwellings or other excluded HampCB rental general stock)

bull maintenance of the fire safety handbook andor emergency procedures manual whichever is applicable (this requirement does not apply to single dwellings)

bull receiving or preparing reports of all fire incidents occurring in the building(s) informing the nominated senior staff member of their contents and arranging for appropriate action

bull providing fire incident reports to line management and to the Department through the region and program and where applicable to the HampCB Asset Manager

bull ensuring that a yearly report is presented to the Regional ExecutiveAgency Board whichever is applicable informing them of the current state of fire safety in all premises for which the departmentagency is responsible

bull ensuring that a Fire Safety Certificate is completed yearly or alternatively as prescribed in these Guidelines

bull being a member of an Emergency Planning Committee or equivalent if the facility has such a committee

The nominated fire risk management officer or EPC may be responsible for several small facilitiesbuildings or a single major building(s) such as an acute hospital but will require one or more appointed deputies to ensure that a responsible person is always available to assume the specified range of duties when the nominated officer is absent

In the event of an emergency at major facilities a nominated person must take command until the fire brigade arrives and act as a focus for liaison purposes thereafter


The nominated fire risk management officers or Emergency Planning Committees are of such importance that they should be directly responsible to the CEO or manager They must have sufficient seniority and proficiency to be able to carry out the required range of their duties effectively

63 General duties and responsibilities of all staff All staff have fire safety duties and responsibilities Line managers are responsible for ensuring that their staff are aware of and observe fire safety policies and instructions They must make it possible for every member of staff to participate in fire safety training and exercises

Effective training in fire fighting practice in evacuation techniques and participation in fire exercises for all personnel without exception is of vital importance Where necessary personnel must have both basic instruction in fire safety and fire training appropriate to their own particular category and the specific needs of their place of work It is essential that all staff

bull understand the character and hazards of fire smoke and toxic fumes

bull know the fire hazards involved in their working environment

bull practise and promote fire prevention

bull know and follow the procedures in which they were trained if fire breaks out

bull report all fires to line management

Staff must be instructed by way of the fire safety training to report to line management instances where properly agreed fire safety procedures are not being implemented or observed For example anything affecting the integrity of escape routes and fire compartments continued use of faulty equipment etc

Staff must be aware that among the most important aspects of fire prevention in facilities are minimising the risks associated with smoking and smoking materials the possibility of wilful fire lighting and the need for a range of good housekeeping measures For example maintenance of clear exit paths and control of storage of combustible materials

Reference must be made to the Fire and Emergency Response Procedures and Training Framework14 for further information

64 Expectations of tenants in Housing amp Community Building rental properties

For HampCB residential tenancy agreements the occupants are entitled to quiet enjoyment of the facility There is therefore limited scope for training in fire safety and it is impractical to impose rigorous fire prevention regimes such as is promoted in the Fire and Emergency Response Procedures and Training Framework

The Department of Human Services will provide educational materials and programs and fire notices as appropriate

14 Available at httpwwwDepartment of Human Servicesvicgovaucapdevemergprochtm


65 Reporting of fires The collection of data from fire incidents in health care and other premises is an important tool to measure the effectiveness of the fire risk management policy Lessons can be learned from routine reports as well as from the comparatively few serious fires experienced in Department of Human Services owned or occupied facilities

Small outbreaks of fire that are rapidly extinguished (for example smouldering paper in waste paper baskets started by carelessly discarded cigarettes) must always be reported to line management in accordance with Department of Human Services reporting policy

Large fires can develop from insignificant beginnings fire brigades advise that they must be called to attend all fires

Serious fires (involving death serious injury closure andor significant damage to parts of a building or its contents) must always be reported in a timely manner In the first instance a fire report must be sent promptly to the line manager and to the nominated fire risk management officer if the officer did not prepare the report

Details of all outbreaks of fire to which the fire brigade is called in Department of Human Services premises or Department-funded facilities must be reported promptly by the nominated fire risk management officer or CEO

Department of Human Services incident reporting policies and procedures specify reporting requirements


70 Maintenance and testing All components of the fire safety strategy for a building require regular maintenance and testing in order to ensure the levels of fire safety are not compromised over time

The building surveyor must determine the required essential safety measures specified in the building regulations and in the appropriate Department of Human Services Guidelines

The essential safety measures in any Department of Human Services owned or occupied facility or a building occupied by a Department of Human Services funded agency must as a minimum be maintained in accordance with Part 12 of the Building Regulations It is the responsibility of the CEO of the relevant service network agency or facility to ensure that the requirements are being met

Part 12 of the Building Regulations prescribes the requirements for the maintenance of essential safety measures including requirements for preparing an annual essential services report Further details and a copy of the required annual essential safety measures report form are available in Appendix 3 or at httpwwwbuildingcommissioncomauwwwhtml1176-building-formsasp

For guidance on the maintenance of human factors through training reference must be made to the Department of Human Services Fire and Emergency Response Procedures and Training Framework


Appendix 1 Definitions used in these Guidelines Bed-based care support or supervision Where sleeping accommodation is provided for occupants of buildings subject to these Guidelines and staff provide care support or supervision at all times that occupants are present

Boarding house A boarding house guest house hostel or similar in which more than 6 unrelated persons would ordinarily reside but full time staff are not provided

Building Code of Australia (BCA) The current version of the Building Code of Australia as published by the Australian Building Codes Board Definitions in the Building Code of Australia have the same meaning when used in these Guidelines

Building(s) subject to these Guidelines A building that is bull owned andor operated by Department of Human Services HampCB or a community service

organisation for the purpose of providing bed-based care support or supervision services that are either directly delivered or funded by Department of Human Services through a service agreement

or bull owned andor operated by Department of Human Services or HampCB and provide sleeping

accommodation for occupants

Building surveyor A person who is registered under the Category of Building Surveyor by the Building Practitioners Board and has appropriate experience in fire safety to apply and interpret these Guidelines

Competent person Owners may appoint a person in certain situations to undertake testing or reporting functions of existing safety features An owner must ensure that the person they appoint is suitably qualified and competent in the task that they are performing

A competent person is a person who has acquired ndash through training qualification or experience (or a combination of them) ndash the knowledge and skills enabling the person to perform the task correctly In the context of the weekly safety check that person would need to be competent in inspecting and testing the listed measures Whoever is responsible for ensuring a particular task is carried out must determine that the person engaged to carry out that task is competent to do so

In determining a personrsquos competency due consideration must be given to their qualifications the training they have received relevant to the task at hand and their previous experience in doing similar tasks Some tasks for example electrical or plumbing installation inspection and testing will require a particular competence such as a formal qualification andor licence Therefore a qualified and licensed person can only undertake such work Where tasks other than those requiring a formal qualification andor licence can be carried out by a lsquocompetent personrsquo who does not have formal qualifications such a person must still be able to demonstrate they have the necessary training qualification or experience (or a combination of them) to carry out the inspecting testing and reporting task in a competent manner


Congregate care facility A lsquoresidential care building or group of buildingsrsquo as defined in the building regulations with on-site support or care staff accommodating more than eight persons where 10 per cent or more require physical assistance in conducting their daily activities and to evacuate the building during an emergency If a hospital or major part of a hospital is predominantly used for the accommodation of the aged or those with mental illness or intellectual disabilities the parts providing these services must be treated as congregate care facilities

Community-based houses A house of a typical domestic type construction and layout with staff accommodating no more than twelve persons of which not more than one requires physical assistance in conducting their daily activities and to evacuate the building during an emergency

Day centres A building or part of a building that is used for educational training rehabilitation and similar functions but not used for residential purposes Such facilities include kindergartens clubs halls occupational therapy centres clinicsday programs adult training support service etc

Day hospital A building or part thereof used to provide same day services or treatment to four or more patients at the same time This includes

bull facilities that provide on an inpatient basis treatment for patients that would render them incapable of taking action for self-preservation under emergency conditions without assistance from others

bull facilities that provide on an inpatient basis surgical treatment requiring general anaesthesia

Desktop fire safety audit An audit of fire safety issues and measures based on a review of documentation such as design development documentation This type of audit does not involve a site inspection and therefore relies on a careful examination of the documentation It provides data for a fire risk assessment on new facilities and major refurbishments The desktop fire audit must address the same matters as a fire safety audit on an existing building except that minimum requirements for matters that would otherwise be observed during an audit (such as maintenance fire prevention and training) must be stated and considered in the subsequent risk assessment

Exercises Training programs that are given to staff andor occupants to explain promote and understand the emergency evacuation system Examples could be walking occupants through the egress system explaining waiting areas listening to alert and evacuation tones practicing door closing etc Exercises are not usually done in real time as a lsquotestrsquo evacuation but are a training process For example additional exercises might be done to improve the effectiveness of the building evacuation

Existing building (see also lsquoNew Buildingrsquo) A building subject to these Guidelines which was used for the purpose being considered under the application of these Guidelines at the time of initiation of a fire safety audit or re-audit fire risk assessment or fire safety compliance check

False alarm Activation of an alarm system in a building that did not result from the effects of fire Alarm activation by burnt toast cooking appliances fireplaces etc are not false alarms according to this definition Alarm activation by water vapour (steam) animal hair lint faulty installation wiring corrosion lack of maintenance etc are false alarms according to this definition


Fire exercises Real-time full-scale practice evacuations done to test and record actual evacuation capability and time

Fire risk assessment An assessment of the potential for the realisation of an unwanted fire event which is a function of the hazard its probability and consequences A fire risk assessment is one or more normally a combination of a

bull qualitative analysis bull quantitative analysis bull regulatory assessment

depending upon the particular application

Fire risk assessments may be undertaken by independent fire safety engineers for specific buildings or may form part of the specific technical outcomes of a Guideline (for example Capital Management Branch Capital Development Guidelines 78 and 79)

Fire risk management (process) The process of determining by fire safety audits fire safety re-audits and fire risk assessments whether an appropriate level of fire safety is achieved in a building As a minimum an appropriate level of fire safety means the minimum statutory requirements applicable to that building and implementation of the outcomes of a fire risk assessment based of use occupant profile staff profile (if any) fire prevention training and ongoing maintenance

Fire safety audit The structured auditing of fire safety measures in a building against nominated audit criteria including those relating to life safety as described in Australian Standard 4655-2005 Definitions in Australian Standard 4655-2005 have the same meaning when used in these Guidelines Audits may be undertaken by independent fire safety engineers or Department of Human Services staff depending on the type of building For new buildings change of use of a building or where major renovation work is proposed the fire safety audit can consist of a desktop fire safety audit

Fire safety compliance check A check performed in lieu of a fire safety audit and fire risk assessment to facilities to which the following Department Guidelines apply Capital Development Guideline 74 Supported Community-Based Houses and Capital Development Guideline 77 Community-Based Houses Typically this function would be performed by a building surveyor

For existing buildings the check involves a site inspection of the building review of existing documentation and for buildings to which guidelines 74 and 77 apply a discussion with the building manager or care provider For new buildings the check involves a desktop fire safety audit review of design documentation and for buildings to which guidelines 74 and 77 apply a discussion with the proposed building manager or care provider

Fire safety engineer A person who is registered in the Category of Engineer Class of Fire Safety Engineer by the Building Practitioners Board and has appropriate experience in conducting fire safety audits and risk assessments

Fire safety handbook (formerly fire safety plan) A document that defines the fire safety strategy for a building in terms of the required levels of performance design parameters and maintenance requirements for each physical or human measurefactor


Fire safety re-audit The structured re-auditing of previously established fire safety measures in a building against established audit criteria The re-audit determines if all building work or use changes in the period since the original audit have been undertaken in accordance with the fire safety strategy for that building and that any changes to statutory requirements have been incorporated into the fire safety strategy A fire safety re-audit is not a new fire safety audit but only an audit of the changes to the building use or legislation since the original audit

Fire safety strategy A combination of physical and human measuresfactors including maintenance and management systems which have been specified to achieve the nominated fire risk management objectives

HampCB Housing and Community Building is a Division of the Depatment of Human Services Previously HampCB was known as Office of Housing (OoH)

High-rise building A building which has an effective height as defined in the BCA of more than 25 metres

Hospital A building or part thereof used on a 24-hour basis for medical obstetrical or surgical care of four or more inpatients including acute hospitals

Human factors (measures or precautions) Occupant characteristics management practices emergency control organisation training etc that may affect fire safety Human measures or precautions typically relate to facilitiesbuilding management issues

International Fire Engineering Guidelines The provisions of the International Fire Engineering Guidelines published by the Australian Building Codes Board that apply to Australia Definitions in the International Fire Engineering Guidelines have the same meaning when used in these Guidelines

Interim fire safety precautions Temporary or permanent fire safety measures to address severe fire hazards prior to the implementation of full fire safety upgrade works Interim measures do not as a matter of course bring facilities to compliance but are required to address immediate and urgent risks

Low-rise building A building which has a rise of 3 or fewer storeys as defined in the BCA

Medium-rise building A building which has a rise of more than 3 storeys but an effective height of less than 25 metres as defined in the BCA

Must (see also lsquoshouldrsquo) Means the requirement is mandatory

New building (see also lsquoexisting buildingrsquo) A building not yet constructed or under construction or a building previously used for a different use or previously of a different BCA classification to the purpose being considered under the application of these Guidelines at the time of initiation of a fire safety audit or re-audit fire risk assessment or fire safety compliance check


Nominated fire risk management officer A senior manager normally reporting directly to a CEO who has overall responsibility for fire risk management The nominated fire risk management officer may have responsibility for more than one building and may carry out other duties in addition to those required of the nominated fire risk management officer

Occupant The persons (ie clients tenants residents patients guests or visitors) who may be present in a building subject to these Guidelines for the purposes of sleeping accommodation

Occupant Profile One or more of the following

Ambulant (Type 1) An occupant who is able to understand and respond to an alarm and able to independently evacuate without staff present in the building

Ambulant (Type 2) An occupant who is able to understand and respond to an alarm and can evacuate with staff intervention (for example staff implement the evacuation plan including providing verbal instructions coordination supervision and limited physical assistance such as hand or arm holding)

Ambulant (Type 3) An occupant who is not able to understand and respond to an alarm but can evacuate with staff intervention (for example staff implement the evacuation plan including providing verbal instructions coordination supervision and limited physical assistance such as hand or arm holding)

Non-ambulant (Type 4) An occupant who is able to understand and respond to an alarm but may not be able to independently evacuate They will require verbal instructions and substantial physical assistance (that is removal from bed and placement in a wheelchair stretcher etc) from staff to evacuate

Non-ambulant (Type 5) An occupant who is not able to understand or respond to an alarm and not able to evacuate without physical assistance They will require verbal instructions and substantial physical assistance (that is removal from bed and placement in a wheelchair stretcher etc) from staff to evacuate

Non-ambulant (Type 6) An occupant who cannot be evacuated

Physical factors (measures or precautions) Fire protection equipment lining materials architectural layout egress provisions etc that may affect fire safety Physical measures or precautions generally relate to capital works

Practical (practicable) Practical (practicable) regarding

bull the severity of the hazard or risk in question bull the state of knowledge about the hazard or risk and any ways of removing or

mitigating that hazard or risk bull the availability and suitability of ways to remove or mitigate that hazard or risk bull the cost of removing or mitigating that hazard or risk

Primary means of exit A continuous and unobstructed way of getting from any point in the building to a road or open space which would likely be the first choice for an occupant in a fire emergency



Residential Care Building Means a building which is a place of residence where 10 per cent or more of persons who reside there need physical assistance in conducting their daily activities and to evacuate the building during an emergency (including any residential care service State funded residential care service or supported residential service as defined in the Health Services Act 1998 and an aged care building) but does not include (a) a hospital or (b) a dwelling in which 2 or more members of the same family and not more than 2 other

persons would ordinarily be resident or (c) a place of residence where only one resident needs physical assistance in conducting their

daily activities and to evacuate the building during an emergency

Secondary means of exit An alternative means of escape which can be used if the primary means of escape is not available Windows that can open may be used as a secondary means of escape but not as a primary means of escape

Secure facility A building or part of a building that provides sleeping facilities and is occupied by persons who are generally prevented from taking self-preservation action because of security measures not under the personrsquos control Examples include correctional institutions detention facilities secure welfare facilities community residential centres training centres substance abuse centres and some mental health facilities It may also include other buildings on the site such as program spaces

Should (see also lsquomustrsquo) Means the requirement is not mandatory

Sole occupancy unit (SOU) As defined in the BCA Where a building is used as a single dwelling or house then it will be one SOU Examples include single dwellings community-based houses and supported community-based houses

Staff Profile One or more of the following

Staff Profile Type 1 No staff present Staff Profile Type 2 Staff present only as occupant day-to-day needs require Staff Profile Type 3 At least one staff member present when occupants are present

but may be asleep at night Staff Profile Type 4 At least one staff member present when occupants are present

awake at all times

Supported community-based houses Houses of a typical domestic type construction and layout that may be on separate sites or grouped together on one site There is on-site support or care staff present when residents are at home and accommodation for no more than eight persons and where more than one of the person requires physical assistance in conducting their daily activities and to evacuate the building during an emergency

Appendix 2 Using the occupant risk matrix The following approach allows a structured assessment of fire safety based on occupant and staff profile and may be of assistance in determining Guideline applicability and appropriate levels of fire safety in any building containing sleeping accommodation

A21 Determining occupant profile Occupant profiles are defined in this Guideline From these definitions the specific occupant profiles can be determined based on information or advice from the building owner or operator or other persons with knowledge of the occupants and final use of the building

If the building has a number of varying occupant profiles the most onerous profile type must be applied for the purposes of these tables except where a building has all occupant profile types 1-3 and only one occupant profile type 4 or 515 This is because the physically assisted evacuation of one person can be undertaken in conjunction with non-physically assisted evacuation of others asingle evacuation Where more than one staff evacuation lsquocyclersquo is required a risk assessment must always be undertaken and the minimum requirements will usually be installation of automatic fire sprinklers mains powered (240 volt) smoke alarms with battery backup staff training and building requirements

s a

A22 Determining staff profile Staff profiles are defined in this Guideline From these definitions the specific staff profiles can be determined based on information or advice from the building owner or operator or other persons with knowledge of the occupants and final use of the building It must be noted that determination of staff profile does not consider numbers of staff staffoccupant ratios may still require determination by a fire risk assessment

A23 Assessing the results of the occupant risk matrix Once the occupant and staff profiles are confirmed the Occupant Risk Matrix (ORM) in Table A21 can be used to reference which specific Guideline might be applicable whether a project specific risk assessment is required or whether the staff or occupant profiles need to be reviewed

A lsquoRisk Type Arsquo outcome from the ORM indicates that a specific Guideline may be applicable or if not the requirements of that Guideline may form the basis for the initial trial fire safety strategy for that building

A lsquoRisk Type Brsquo outcome from the ORM indicates that the occupantstaff profiles require further analysis by undertaking a fire risk assessment The fire risk assessment may require changes to occupantstaff profiles or installation of significant fire safety systems

A lsquoRisk Type Crsquo outcome from the ORM indicates that the occupantstaff profiles are unacceptable and must be changed Additional fire safety systems or a risk assessment cannot be used to change the outcome

15 For example this is consistent with Guideline 77 Community-based Houses which are defined as a lsquoHouse of a

typical domestic type construction and layout with a total floor area up to 350 m2 with 24-hour staff accommodating no more than 12 persons of which not more than one requires assistance to evacuate the building during an emergency


Table A21 Occupant risk matrix

Occupant Profile

Staff Profile

Ambulant (Type 1) Ambulant (Type 2) Ambulant (Type 3) Non-ambulant (Type 4)

Non-ambulant (Type 5)


Staff Profile Type 1 No Staff present RRRiissskkk TTTyyypppee AAA i e

(G78 G79 or G710) RRRiissskkk TTTyyypppee CCC

16 A risk assessment undertaken in accordance with Guideline 72 Guidelines 73 75 and 76 also require a risk assessment to be undertaken in all circumstances A lsquoGroup Brsquo risk

assessment is required because either no specific guideline is appropriate or staff response may not be sufficient based on the occupant profile 17 Staffoccupant ratios may still require determination by risk assessment

i e (staff or occupant profile must be changed )

RRRiisskkk TTTyyypppeee CCC is (staff or occupant profile must be changed )



RRRiisskkk TTTyyypppeee CCC is (staff or occupant profile must be changed)

Staff Profile Type 2 Staff present only as occupant day-to-day needs require

RRRiissskkk TTTyyypppee AAA i e (G78 G79 or G710)

RRRiissskkk TTTyyypppee BBB i e (requires risk assessment16)

RRRiisskkk TTTyyypppeee BBB is (requires risk assessment116)




Staff Profile Type 3 At least one staff member present when occupants are present but may be asleep at night17

RRRiissskkk TTTyyypppee AAA i e (G77 )

RRRiissskkk TTTyyypppee AAA i e (G73 G74 or G77 )

RRRiisskkk TTTyyypppeee AAA is (G73 G74 or G77 )

RRRiisskkk TTTyyypppeee AAA is (G73 G74 or G77)


RRRiisskkk TTTyyypppeee CCC is (Staff or occupant profile must be changed)

Staff Profile Type 4 At least one staff member present when occupants are present awake at all times17

RRRiissskkk TTTyyypppee AAA i e (G76 or G77)

RRRiissskkk TTTyyypppee AAA i e (G73 G74 G75 G76 or G77 )

RRRiisskkk TTTyyypppeee AAA is (G73 G74 G75 G76 or G77 )



RRRiisskkk TTTyyypppeee AAA is (G76)


Appendix 3 Fire Safety Certificate ndash 71 and the Essential Safety Measures Report Building legislation requires that all buildings other than buildings of Class 1 Occupancy must have the essential safety measures determined by a building surveyor The owner must comply with the determination by maintaining the measures to the standard to which they were installed and reporting on an annual basis Examples of essential safety measures are smoke alarms sprinklers exits and exit doors and floor and wall linings Further details and a copy of the required annual essential safety measures report form are available at httpwwwbuildingcommissioncomauwwwhtml1176-building-formsasp

An annual Fire Safety Certificate must be submitted to confirm the process of continual monitoring of the building(s) safety standards at premises required to satisfy the Department of Human Services Series 7 Guidelines - Fire Risk Management and policies for Departmentally owned or operated services

An example of the information and format of an annual Department of Human Services FRM Guideline Fire Safety Certificate - 71 is shown below


Fire Safety Certificate ndash 71 (for Government owned facilities either operated by a Funded Organisation or DHS staffed)

Reporting Period 20_____ - 20_____


The Certificate is to be completed annually by 30 September by the delegated Program Manager in consultation with the Regional Fire Risk Management Coordinator (FRMC) and where applicable the Emergency Planning Committee (EPC) is to confirm that premises coming within their control satisfy the Department of Human Services Series 7 Guidelines - Fire Risk Management and policies for Departmentally owned or operated services

Refer overleaf for instructions on completion of this certificate

Property Address ______________________________________________

(provide a schedule for multiple sitesbuildings)

1 I certify that from the information obtained and to the best of my knowledge that the property listed above or on the attached list has been assessed in terms of the current statutory and departmental fire safety requirements as follows

The DHS Capital Development Fire Risk Management Guidelines Series 7 Fire Risk Management specifically Guideline 71 amp Guideline 7____ (insert relevant guideline number)

The Date of the last fire safety compliance check fire safety auditrisk assessment report is helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip or as indicated in the attached schedule of properties

The relevant provisions of the Building Act and building regulations are being met including the annual Essential Safety Measures report

YesNo

Outstanding works and actions from last audit(s) are in the attached schedule with details of Immediate and Priority and the Action Plan to address these items over the next 12 months

The Emergency Response Policy and procedures required by the DHS Guideline Fire amp Emergency Response Procedures and Training Framework (FERPTF) are being met

OR FERPTF does not apply and the requirements to the level specified in the Australian

Standards (ie AS3745 as amended) are being met

YesNo

OR YesNo

SPECIAL REQUIREMENT Where a facility is managed by a Funded Organisation the DHS Service Agreement requirements for fire safety management have been met and a Fire Safety Certificate No4 signed by the Funded Organisation has been received

YesNo

or

Not applicable

2 I certify that any identified fire related issues have been discussed with the regional Fire Risk Management Co-ordinator as per the attached report

3 I certify that all reasonable steps have been taken for the preceding twelve-month reporting period to ensure that the fire safety measures fulfil their required purpose and that procedures are in place for this to continue for the next twelve months

Signature __________________________ Date ________

Name __________________________ Title _________________________

(Note the signatory must not be delegated to less than two levels below that of the Regional Director)


DHS Capital Development Guideline 71 - Fire Safety Certificate

EXPLANATORY NOTES FOR SIGNATORIES

Application This certificate is only to be used for government owned sites Type of service bed-based with 24-hour rosteredlive in staff supportsupervision Premises owned or leased by the State Government (the Crown the Secretary of the department or the Director of Housing) but not rental general stock Other Where the departmentrsquos Guidelines Series 7 Fire Risk Management do apply

Services may include disability (including respite) placement and support secure welfare juvenile justice mental health drug and alcohol and Supported Accommodation Assistance Program (SAAP) residential services

Certification is retrospective for the preceding twelve-month financial period Certificates fall due after 1 July each year and for Departmental reporting purposes should be completed before 30 September in the same year

Service Agreement For government owned properties operated by a Funded Organisation (FO) a signed Certificate No4 must be provided by the Funded Organisation before the 71 fire safety certificate can be completed by the Region

Certificate No 4 is the means for the Funded Organisation to certify to the owner that the facility has been maintained and will continue to be maintained for the next twelve months and that any outstanding fire safety items that do not satisfy the Series 7 Capital Development Guidelines have been reported reviewed and scheduled for action by a determined date It also certifies that emergency management and evacuation procedures are in place and exercised to meet Australian Standards AS 3745

DHS Capital Development Guidelines Series 7 - Fire Risk Management The FRM Guidelines assist in determining the appropriate level of fire safety to be afforded to clients accommodated at the facility and takes into account the requirements of relevant acts regulations and the BCA

Audits To satisfy these requirements the FRM Guidelines require audits of the fire safety features and in some instances fire risk assessments to be undertaken A audit process is programmed on a 5 yearly rolling basis New works undergo a desk-top assessment that includes certification If a facility has not had an audit or re-audit conducted within the past 5 years or if an audit has been conducted and interim or priority recommendations are outstanding further investigation should be undertaken before completing the fire safety certificate

Annual Essential Safety Measures Report (ESM Report) Consistent with the Building Regulations requirements for maintenance of buildings the Guidelines also require essential safety measures maintenance and testing of DHS facilities An annual Essential Safety Measures report for each facility must be completed (applies to properties in use for a period of twelve months) as evidence of the maintenance required and undertaken In completing this certificate it is important to confirm that the ESM report has been developed Annual fire maintenance declarations provided by the fire services contract manager (eg Housing amp Community Development COMAC) together with other records of maintenance at the facility assist in providing evidence of the maintenance undertaken in the previous twelve months and will be required to complete the annual ESM Report

The DHS Fire amp Emergency Response Procedures and Training Framework (FERPTF) document focuses on policies and procedures for fire amp emergency response procedures and training Under FERPTF facility management is required to ensure that staff are trained drills are conducted and that documented emergency procedures are in place A fundamental requirement in managing this and other FERPTF requirements is the establishment of Emergency Planning Committees (EPC) For facilities managed by a Funded Organisation where the program has not mandated FERPTF a formalised process is required to ensure the requirements of AS3745 are being met

Schedule of Fire Safety Works In most instances a facility is likely to have some outstanding fire safety work whether it is a drill not being conducted a minor audit recommendation outstanding or a fire extinguisher with an overdue service Whilst technically this may be viewed as a non-compliance of the property it should not prevent the fire safety certificate from being completed with exemption attached However if there are identified fire safety related issues of a more severe nature eg sprinklers not installed this should be discussed with your regional Fire Risk Co-ordinator who may need to undertake a risk assessment to determine what action is required and the detail that is to be included in a report



SCHEDULE OF FIRE SAFETY WORKS

DHS Agency Name helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Property Details helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Street AddressPostcode helliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphelliphellip

Outstanding fire safety work from the last fire safety audit report and the current annual Essential Safety Measures report

Status

Description of item to action Priority

Immediate P1

Order of Cost Estimate

Actions Timing for implementation completion

Comments

IssuesImpacts




Appendix 4 Approval process for implementation of fire risk management projects

Secretary of the Department of Human Services

Fire Risk Management Strategy Steering Committee

Networks

Eight Emergency Planning Committees

Individual Facilities Department of Human Services owned and operated

Department of Human Services owned but operated by others

Statutory Authorities Operated for the Department of Human Services

Chief Executive Officers or Managers

Nominated Officer with Fire Risk Management Responsibilities

Summary Department of Human Services management and operational arrangements The following chart provides a guide to the responsible party with respect to the operation and maintenance of the Department of Human Services owned operated and leased buildings

Policy bull Department of Human Services

Capital Management Branch (CMB) (strategic policy)

Programoutput groupagency (operationalresourcing)

Building Standards

bull Owner Is accountable for the construction use and safety of the building

Is responsible for ensuring that the building is constructed and maintained in accordance with the requirements of the building regulations with operator advising on service requirements

Building Maintenance

bull Operator

bull Owner

To ensure functional systems are in place and advise owner

To comply with the maintenance determination in relation to that building or place and prepare the annual report

Operational Readiness

bull Operator Provider of the service (manager of building site or service)


Appendix 5 Recommended line of reporting roles and responsibilities

Secretary

Divisional Director

Capital Management Branch (CMB)

Regional Director PROGRAMS

Regional Fire Risk Management Coordinator

Regional Emergency

Metropolitan Regional Office and FRM Coordinators do not have responsibility for clinical health services

Manager Of BuildingSiteService Contract Manager Provider Management

AgenciesNon-Government Organisations (S)

Divisional Director Regional Fire Risk Management Coordinator bull Approval of projects for funding

bull Receipt of evaluation reports bull Principal contact for implementation of fire risk

management strategy CMB Responsibility bull Facilitate Regional Emergency Planning Committee

bull Strategic policy development and implementation bull Coordinate audit and fire risk assessment program bull Advisory role bull Formulate recommendations and priorities bull Coordination with programsregions bull Oversee and report on regional progress

bull Identify trends Programs bull Prioritise funding requirements

Responsibility at buildingsiteservice bull Develop specific operational policies for the client and group(s)

bull Prioritise funding requirements bull Arrange compliance audits for sites bull Arrange compliance audits for sites bull Consider recommendations bull Consider recommendations bull Commission auditfire risk assessment as part of

regional program bull Commission auditfire risk assessment as part of regional program bull Recommend priorities from fire risk audits

bull Recommend priorities from fire risk audits bull Forward Incident Report bull Coordinate training bull Develop fire and emergency response procedures

bull Carry out training bull Regularly review site procedures bull Ensure fire safety systems are adequately

maintained

Appendix 6 Fire risk management mdash incident reporting Fire Incident Reporting Procedure

DHS incident report prepared at facility

Fire report reviewed by CEOline managerregional directorfire risk management coordinator Corrective actions implemented if necessary

CEO or delegate signs and distributes report in accordance with Department of Human Services incident reporting policies and procedures

Yearly Reporting Procedures Regional Emergency Planning Committee supplies relevant CEO or manager with evidence for all premises of bull assessments of fire safety by competent practitioners bull agreed programs for implementation of required upgrades bull details of drillsexercises bull summary of reported fire incidents bull fire safety works undertaken bull maintenance of essential services

Nominated building fire risk management officer initiates the Fire Safety Certificate yearly in July for signature by CEOline manager

Regional fire risk management coordinator reviews certificates and prepares a report for the Regions Program Director and CMB



71 Fire risk managementpolicy and procedures

Department of Human Services

Capital Management Branch



YesNo

YesNo

Application This certificate is only to be used for government owned sites

71 Fire Risk Management Policy and Procedures Edition 9 copy State of Victoria 2008 ii

Acknowledgments

copy Copyright State of Victoria 2008

Published by the Capital Management Branch Financial and Corporate Services Division Victorian Government Department of Human Services

This publication is available at Department of Human Services Internet address wwwcapitaldhsvicgovauTechnicalGuidelinesFireRiskManagement

Disclaimer

The purpose of these fire risk management guidelines is to provide appropriate levels of fire safety for occupants of a building subject to these Guidelines by enabling appropriately qualified professional advisers such as registered fire safety engineers and building surveyors to

bull audit and assess fire risk

bull recommend steps to minimise fire risk

bull assess and report on acceptable standards of fire safety

in specific settings

The use of the Guidelines is subject to the following

a) The Guidelines do not constitute all of the possible fire safety matters that may apply to a specific situation but are provided for assistance in determining appropriate fire safety measures It is up to individuals acting with appropriate professional advice to determine their application to particular situations

b) Guidelines 73 to 710 must be used for purposes only within the range set out in the lsquoIntroductionrsquo section at the start of each document

c) In addition to the fire safety requirements and standards in the Guidelines owners occupiers and operators of facilities may be subject to various other statutory common law and contractual obligations They must seek advice including legal advice on the existence and scope of these obligations

The Department of Human Services and organisationsindividuals involved in the preparation of these documents make no representation that the Guidelines are suitable for any particular situation and accept no responsibility for any loss or damage arising out of any decision to apply the Guidelines to any particular situation

Definitions

Defined terms are in italics when first used in each guideline A list of all definitions can be found in Appendix 1 of Guideline 71










33 New buildings 9




































Programs 38









Objectives






or




























































measures

















































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo











33 New buildings 9




































Programs 38









Objectives






or




























































measures

















































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo























Programs 38









Objectives






or




























































measures

















































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo







Objectives






or




























































measures

















































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo
























































measures

















































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo
































or

















or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo









or





Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo


Flowchart 1





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo





Table 1





na na na na


na na na na


















Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo


Table 1













































na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo




























na na na



Yes3














Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo










Yes3



Yes3







No4



No4



No4


















































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo











































































































































awake at all times





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo





s a










Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo



Occupant Profile

Staff Profile


















































YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo

















YesNo





YesNo

OR YesNo


YesNo

or

Not applicable



Signature __________________________ Date ________

Name __________________________ Title _________________________






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo






















Status


Immediate P1



Comments

IssuesImpacts







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo







Networks











Building Standards




bull Operator

bull Owner







Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo




Secretary

Divisional Director




Regional Emergency














maintained















YesNo

YesNo
















YesNo

YesNo


Capital Development Guideline - Department of Health ... FRM Policy...2.0 The Guidelines and their...

Documents

Transcript of Capital Development Guideline - Department of Health ... FRM Policy...2.0 The Guidelines and their...