STATE OF NEW YORK - DEPARTMENT OF HEALTH



STATE OF NEW YORK - DEPARTMENT OF HEALTH

Limited Review Application

GENERAL INSTRUCTIONS

| | |

|This application is necessary for those proposed projects which require a |If a limited architectural review is required, submit this application along with |

|limited architectural review as explained below: |a brief description on the facilities letterhead including the appropriate fee to:|

| | |

|Limited architectural review is required if the proposal has a total project |Bureau of Project Management |

|cost of under $3,000,000 and affects safety or sanitary conditions as described |Office of Health Systems Management |

|in the State Hospital Code Section 710.1(c)(5). |NYS Department of Health |

| |433 River Street, 6th Floor |

|The application consists of a cover sheet and three schedules as listed below: |Troy, New York 12180-2299 |

| | |

| |Payment of fees should be by check made payable to the New York State Department |

| |of Health. |

| | |

|Each of these schedules contains instructions for completion. |Please include any information and documentation required to determine the |

| |acceptability of the proposal. |

| | |

| | |

| |As an alternative to submitting supporting documentation, in certain cases (i.e. |

| |projects with very limited scope of work), a written certification by an architect|

| |or engineer licensed by New York State certifying that the project complies with |

| |Part 711 of 10 NYCRR, (sample below) may be submitted to the Bureau and should be |

| |noted on the cover sheet by checking the appropriate line. |

REVISED *June 9, 2009 R2*

SAMPLE ARCHITECT’S OR ENGINEER’S LETTER OF CERTIFICATION

FOR PROPOSED CONSTRUCTION

This alternative is to be submitted on Architect’s or Engineer’s letterhead with applications eligible for limited review as specified in the application instructions.

|New York State Department of Health |RE: |Name: | |

|Bureau of Architectural & Engineering Facility Planning | |Location | |

|433 River Street 6th Floor | |Description | |

|Troy, New York 12180-2299 | | | |

Gentlemen:

This is to certify that under the terms of my contract for the above-named facility to provide services to design, prepare working drawings and specifications, and during construction to make periodic visits to the site and to perform such other required services to familiarize myself with the general progress, quality and conformance of the work, I have ascertained that to the best of my knowledge, information, and belief, this project is designed/will be designed (select one) in substantial compliance with the provisions of the construction sections of the State Hospital Code, which is in effect at the time this application is being submitted.

I also certify that I have read and understood the conditions of Section 710.1 of 10 NYCRR.

| | | | |

|(Name of Architect or Engineer) | |(Date) | |

| | | | |

|(Professional New York State License Number) | | | |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

|OPERATING CERTIFICATE NO. |FACILITY NAME |PFI NO. |

|      |      |      |

|FACILITY ADDRESS – STREET & NUMBER |NAME AND TITLE OF CONTACT PERSON |

|      |      |

|CITY |COUNTY |ZIP |STREET AND NUMBER |

|      |      |      |      |

|CERTIFIED OPERATOR |CITY |STATE |ZIP |

|      |      |      |      |

|TOTAL PROJECT COST | | |TELEPHONE NUMBER |

| |$0.00[pic]0.00 | | |

|(FROM SCHEDULE 1): | | |      |

Use the following chart to provide a brief outline of the proposed project. Take the facility type code from Appendix C and enter it in column (1). Take the code and description of each proposed solution/action from Appendix B and enter in columns (2) and (3). Take the code and name of the functional area(s) affected from Appendix A and enter in columns (4) and (5).

|FACILITY |CODE | |CODE | |

|TYPE |(2) |PROPOSED SOLUTION/ACTION |(4) |FUNCTIONAL AREAS/SERVICES |

|(1) | |(3) | |(5) |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

|  |   |      |    |      |

PLEASE COMPLETE THE FOLLOWING:

| | |

| 1. Is an Architect’s Letter of Certification attached? | Yes No N. A.       |

| | |

| 2. Are plans for proposed construction attached? | Yes No N. A.       |

| | |

| 3. Are Physicist’s Report and drawings attached? | Yes No N. A.       |

|(If project involves radiation producing equipment) | |

| | |

| | |

4. A Project Narrative (describing scope of work) is attached: Yes      

(This is mandatory)

AUTHORIZING SIGNATURE

The undersigned Chief Executive Officer hereby certifies under penalty of perjury that he is duly authorized to subscribe and submit this application and that the information contained herein and attached hereto is accurate, true and complete in all material aspects.

| | | |

|SIGNATURE | |DATE |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

Total Project Cost

INSTRUCTIONS: Use this table to show a breakdown of the costs of the proposed project

|ITEM |ESTIMATED PROJECT COST |

|1.1 Land Acquisition |$ |      |

|1.2 Building Acquisition |$ |      |

| | |

|2.1 New Construction |$ |      |

|2.2 Renovation and Demolition |$ |      |

|2.3 Site Development |$ |      |

|2.4 Temporary Power |$ |      |

| | |

|3.1 Design Contingency |$ |      |

|3.2 Construction Contingency |$ |      |

| | |

|4.1 Fixed Equipment (NIC) |$ |      |

|4.2 Planning Consultant Fees |$ |      |

|4.3 Architect/Engineering Fees |$ |      |

|4.4 Construction Manager Fees |$ |      |

|4.5 Other Project Fees (Consultant, etc.) |$ |      |

| | |

|5.1 Movable Equipment |$ |      |

| | |

|6. Total Basic Cost of Construction (Total 1.1 thru 5.1) |$ |0[pic]0.00 |

| | |

|7.1 Financing Cost (points, fees, etc.) |$ |      |

|7.2 Interim Interest Expense (Total Interest on Construction Loan: |      |

|Amount $       |@       |% for       |months | |

| | |

|8. Total Project Cost w/o Fees (Total 6 thru 7.2) |$ |0[pic]$0.00 |

| | |

|9. Application Fee |Safety Net D&TC's fee is: |$500 | | |

| |All Other Qualifying Applications fee is: |$1,000 |$ |      |

| | |

|10. Estimated Total Project Cost (Total 8 thru 9) |$ |0[pic]0.00 |

If this project involves construction enter the following anticipated construction dates on which your cost

estimates are based.

|Construction Start Date |      |

|Construction Completion Date |      |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

Proposed Plan for Project Financing

INSTRUCTIONS: Use this schedule to indicate how the project will be financed. Check the appropriate box(es) to the right of the section title. If more than one financing method is expected to be used check each applicable section. Follow the individual instructions for each checked section.

TO BE CONSIDERED FOR REVIEW, ALL APPLICATIONS MUST INCLUDE A

COMPLETE COPY OF THE FINANCING PROPOSAL

|A. LEASE | | |

|If any portion of the cost for land, building or |ITEM |COST AS IF |

|Equipment is to be financed through a lease, | |PURCHASED |

|rental agreement or lease/purchase agreement, | | |

|complete the chart at the right. | | |

| | | |

|A complete copy of each proposed lease must | | |

|be submitted. | | |

| |      |$ |      |

| |      |$ |      |

| |      |$ |      |

| |      |$ |      |

| Attachment # |      | |      |$ |      |

|B. CASH | | |

|If cash is to be used, complete the chart at the |Accumulated Funds |$ |      |

|right. | | | |

| | | | |

|Attach a copy of the latest certified financial | | | |

|Statement and interim monthly or quarterly | | | |

|financial reports to cover the balance of time | | | |

|to date. | | | |

| |Sale of Existing Assets* |$ |      |

| |Other – (ie. gifts, grants, **etc.) |$ |      |

| |TOTAL CASH |$ |0[pic]0.00 |

| | | |

|Attachment # |      | | | |

| |*Attach a full and complete description of the assets to be |

| |sold. |

| |Attachment # |      |

| |** If grants, attach a description of the source of financial |

| |support |

| |Attachment # |      |

|C. DEBT FINANCING | |

|If the project is to be financed by debt of any |Principal |$ |      |

|type, complete the chart at the right. | | | |

| | | | |

|Attach a copy of the proposed letter of interest | | | |

|From the intended source of permanent financing. | | | |

|This letter must include an estimate of the | | | |

|Principal, term, interest rate and pay-out period presently being | | | |

|considered. | | | |

| |Interest Rate |      |% |

| |Term |      |Yrs |

| |Pay-out Period |      |Yrs |

| |Type * |      | |

| |* Commercial, Dormitory Authority Bonds, Dormitory |

| |Authority, TELP Lease, Industrial Development Agency |

| |Bonds, Other (identify). |

|Attachment # |      |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

|Space & Construction Cost Distribution | |New |

| | |

| | |Alteration |

(For instruction on completing Schedule 3 see Appendix D)

|LOCATION | | | | | |

| |Code and Functional |Functional |Construction |Total |(ALT) |

| |Category Description |Gross SF |Cost |Construction |Scope |

| | | |per SF |Cost |of Work |

| |(4) |(5) |(6) |(7) |(8) |

|Bldg. |Floor |Sect. | | | | | |

|No. |No. |No. | | | | | |

| | | | | | | | |

|(1) |(2) |(3) | | | | | |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

|      |      |      |      |      |      |      |  |

| | | |Total Construction |      |      |      | |

|Signature |1. If new construction is involved, is it "freestanding"? |Yes | |No |

|Blocks | | | | |

|for preparer | | | | |

|of this | | | | |

|schedule ( | | | | |

| | |

| |2. (Check where applicable) The facilities to be affected by this project are located in a: |

| | | Dense Urban Area | Other Metropolitan or Suburban Area | Rural Area |

| | | | | |

| |3. This submission consists of: | New Construction Report |Number of pages |      |

| | | Alteration Construction Report |Number of pages |      |

| | |

|( REPRESENTATIVE ( | |OR |( PROJECT ARCHITECT, ENGINEER OR ESTIMATOR ( |

|SIGNATURE |SIGNATURE OF PREPARER |

|DATE |DATE |

| | |

|PRINT OR TYPE NAME |FIRM NAME PROJECT ARCHITECT, ENGINEER OR ESTIMATOR |

|      |      |

|TITLE |MAILING ADDRESS |

|      |      |

|DATE |CITY & STATE |

|      |      |

|AREA CODE AND TELEPHONE NUMBER |AREA CODE AND TELEPHONE NUMBER |

|      |      |

Do not use the master copy. Photocopy master and then complete copy if this schedule is required.

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

State of New York Department of Health

|LIST OF FUNCTIONAL AREAS AND |CON | |

|SERVICES, BEDS & EQUIPMENT BY |CODES |INPATIENT SERVICES continued |

|FACILITY TYPE | |112 |Poison Control Center |

|This appendix lists the functional areas and services, beds and |221 |Psychiatric |

|equipment, by facility type, which should be used in describing |222 |Psychiatric (Day/Night) |

|your proposals. They will be reflected on your operating |230 |Radioactive Materials (Diagnostic) |

|certificate when approved. In listing these services in the |231 |Radioactive Materials (Therapeutic) |

|application, do not include any description inside parentheses. |224 |Radioisotope Implantation |

| | |226 |Respiratory Care |

|HOSPITAL | |227 |Respiratory Therapy |

|Use the following listing for hospital proposals: |361 |Self Care |

|CON | |362 |Social Work Service |

|CODES |BASELINE SERVICES |305 |Speech-Language Pathology |

|701 |General Baseline Services (includes Anesthesia, |228 |Therapeutic Radiology |

| |Emergency Procedures, Nursing and Physician |306 |Vocational Rehabilitation |

| |Services) | | |

|733 |Baseline Clinical Laboratory Service | | |

|734 |Baseline Dietetic | |OUTPATIENT SERVICES |

|736 |Baseline Medical/Surgical |491 |Alcohol Rehabilitation O/P |

|741 |Baseline Operating Room |402 |Ambulatory Surgery |

|742 |Baseline Pharmaceutical Service |451 |Audiology O/P |

|744 |Baseline Recovery Room |452 |C.O.R.F. |

| | |423 |Chronic Renal Dialysis O/P |

| |INPATIENT SERVICES |407 |Dental O/P |

|101 |Acute Renal Dialysis |493 |Drug Rehabilitation O/P |

|151 |Alcohol Detoxification |471 |Family Planning O/P |

|152 |Alcohol Rehabilitation |473 |Home Dialysis Training O/P |

|102 |Ambulance |453 |Medical Rehabilitation O/P |

|301 |Audiology |494 |Methadone Maintenance O/P |

|201 |Blood Services |454 |Occupational Therapy O/P |

|103 |Burn Center |425 |Organized Outpatient Department |

|104 |Burn Program |415 |Outpatient Surgery |

|203 |Cardiac Catheterization (Adult) |477 |Part-Time Clinic(s) |

|204 |Cardiac Catheterization (Pediatric) |416 |Pediatric O/P |

|205 |Cardio-Pulmonary Function Analysis |455 |Physical Therapy O/P |

|206 |Cleft Palate Center |418 |Prenatal O/P |

|105 |Coronary Care |420 |Psychiatric O/P |

|208 |Cystoscopy |424 |Respiratory Therapy O/P |

|209 |Dental |479 |Social Work Service O/P |

|210 |Diagnostic Radiology |457 |Speech-Language Pathology O/P |

|153 |Drug Detoxification |429 |Venereal Disease O/P |

|154 |Drug Rehabilitation |458 |Vocational Rehabilitation O/P |

|106 |Emergency Department | |BED TYPE |

|107 |Intensive Care |151 |Alcohol Detoxification |

|213 |Kidney Transplantation |152 |Alcohol Rehabilitation |

|214 |Maternity |103 |Burns Care |

|302 |Medical Rehabilitation |105 |Coronary Care |

|108 |Neonatal Continuing Care |153 |Drug Detoxification |

|109 |Neonatal Intensive Care |154 |Drug Rehabilitation |

|110 |Neonatal Intermediate Care |107 |Intensive Care |

|303 |Occupational Therapy |214 |Maternity |

|215 |Open Heart Surgery (Adult) |302 |Medical Rehabilitation |

|216 |Open Heart Surgery (Pediatric) |701 |Medical/Surgical |

|356 |Pathology Laboratory |221 |Psychiatric |

|218 |Pediatric |108 |Neonatal Continuing Care |

|111 |Pediatric - ICU |109 |Neonatal Intensive Care |

|304 |Physical Therapy |110 |Neonatal Intermediate Care |

| | |218 |Pediatric |

| | |111 |Pediatric ICU |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

|CON | |DIAGNOSTIC AND TREATMENT CENTER |

|CODES |BED TYPE continued |Use the following listing for Diagnostic and Treatment Center |

| | |proposals: |

|220 |Prisoner | | |

|226 |Respiratory |CON | |

|361 |Self Care |CODES |BASELINE SERVICES |

|364 |Special Use |704 |General Baseline (Includes Medical Staff) |

| | | | |

| |EQUIPMENT TYPE | |OPTIONAL SERVICES |

|501 |CT Scanner |401 |Abortion O/P |

|502 |Cobalt Unit |491 |Alcohol Rehabilitation O/P |

|503 |Echo Cardiograph |451 |Audiology O/P |

|504 |Hyperbaric Chamber |406 |Clinical Laboratory Service |

|505 |Linear Accelerator |452 |C.O.R.F. |

|506 |Megavoltage Unit |407 |Dental O/P |

|508 |Ultrasound |408 |Diagnostic Radiology O/P |

|601 |Nuclear Magnetic Resonance Demonstration |492 |Drug Abuse Screening O/P |

| | |495 |Drug Detoxification O/P |

|RESIDENTIAL HEALTH CARE FACILITY |493 |Drug Rehabilitation O/P |

|Use the following listing for Residential Health Care |471 |Family Planning O/P |

|Facility proposals: |472 |Health Education O/P |

|CON | |473 |Home Dialysis Training O/P |

|CODES |BASELINE SERVICES |453 |Medical Rehabilitation O/P |

|702 |General Baseline Services - HRF's |494 |Methadone Maintenance O/P |

| |(includes Medical Services) |413 |Multiphasic Screening O/P |

|703 |General Baseline Services - SNF's |475 |Nursing O/P |

| |(includes Medical Services) |476 |Nutritional O/P |

|731 |Baseline Activities Program |454 |Occupational Therapy O/P |

|734 |Baseline Dietetic |414 |Optometry O/P |

|737 |Baseline Nursing |477 |Part-Time Clinic(s) |

|742 |Baseline Pharmaceutical Service |416 |Pediatric O/P |

|746 |Baseline Social Work Service |478 |Prenatal O/P |

| | |455 |Physical Therapy O/P |

| |OPTIONAL SERVICES |417 |Podiatry O/P |

|301 |Audology |418 |Prenatal O/P |

|352 |Clinical Laboratory Service |419 |Primary Medical Care O/P |

|209 |Dental |420 |Psychiatric O/P |

|210 |Diagnostic Radiology | | |

|474 |Non-Occupant Services |HOME HEALTH AGENCY |

|303 |Occupational Therapy |Use the following listing for Home Health |

| | |Agency proposals: |

|217 |Optometry | |

|304 |Physical Therapy |CON | |

|357 |Physician Services |CODES |BASELINE SERVICES |

|219 |Podiatry |705 |General Baseline (includes Home Health Aide |

|223 |Psychological | |and Medical Supplies, Equipment and Appliances) |

|359 |Religious Services and Counseling |738 |Baseline Nursing (Contract) |

|227 |Respiratory Therapy |739 |Baseline Nursing (Direct) |

|305 |Speech-Language Pathology | | |

| | | |OPTIONAL SERVICES |

| |BED TYPES |481 |Medical Social Services O/P |

|703 |SRF |476 |Nutritional O/P |

| | |454 |Occupational Therapy O/P |

| |EQUIPMENT TYPES |455 |Physical Therapy O/P |

|501 |CT Scanner |482 |Personal Care |

|503 |ECHO Cardiograph |483 |Physicians Services |

|508 |Ultrasound |424 |Respiratory Therapy |

| | |457 |Speech-Language Pathology O/P |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

|LONG-TERM HOME HEALTH CARE |CON | |

|PROGRAM | |CODES | |

|Use the following listing for Long-Term Home Health |452 |C.O.R.F. |

|Care Program Proposals: |423 |Chronic Renal Dialysis O/P |

|CON | |406 |Clinical Laboratory Service |

|CODES |BASELINE SERVICES |407 |Dental O/P |

|707 |General Baseline Services (includes Audiology; |408 |Diagnostic Radiology |

| |Home Health Aide; Homemaker, Housekeeper; |492 |Drug Abuse Screening O/P |

| |Medical Social Work; Medical Supplies; Equipment |495 |Drug Detoxification O/P |

| |and Appliances; Nutritional; Occupational |493 |Drug Rehab O/P |

| |Therapy; Personal Care; Physical Therapy; |471 |Family Planning O/P |

| |Respiratory Therapy; and Speech-Language |472 |Health Education O/P |

| |Pathology) |473 |Home Dialysis Training O/P |

|738 |Baseline Nursing (Contract) |453 |Medical Rehab O/P |

|739 |Baseline Nursing (Direct) |494 |Methadone Maintenance O/P |

| | |413 |Multiphasic Screening O/P |

| |OPTIONAL SERVICES |475 |Nursing O/P |

|357 |Physician Services |476 |Nutritional O/P |

| | |454 |Occupational Therapy O/P |

| |PATIENT CAPACITY |414 |Optometry O/P |

|707 |Designated patient capacity |425 |Organized Outpatient Dept. |

| | |477 |Part-Time Cinic(s) |

|HOSPICE |416 |Pediatric O/P |

|Use the following listing for Hospice Proposals: |478 |Pharmaceutical Service O/P |

|CON | |455 |Physical Therapy O/P |

|CODE |BASELINE SERVICES |417 |Podiatry O/P |

|706 |General Baseline Services (includes Bereavement, |418 |Prenatal O/P |

| |Home Health Aide, Homemaker, Housekeeper, |419 |Primary Medical Care O/P |

| |Nursing, Medical Supplies, Equipment & |420 |Psychiatric O/P |

| |Appliances, Nutritional, Pastoral Care, Personal |421 |Psychological O/P |

| |Care, Physician Services and Psychological) |456 |Recreational Therapy O/P |

|732 |Baseline Audiology |424 |Respiratory Therapy O/P |

|733 |Baseline Clinical Laboratory Service |479 |Social Work Service O/P |

|735 |Baseline Inpatient Services |457 |Speech-Language Pathology O/P |

|740 |Baseline Occupational Therapy |426 |TB Respiratory |

|742 |Baseline Pharmaceutical Service |427 |Therapeutic Radiology O/P |

|743 |Baseline Physical Therapy |429 |Venereal Disease O/P |

|745 |Baseline Respiratory Therapy |458 |Vocational Rehab O/P |

|746 |Baseline Social Work Service |480 |Well Child Care O/P |

|747 |Baseline Speech-Language Pathology | | |

| | | |EQUIPMENT |

| |BEDS |423 |Chronic Renal Dialysis Stations |

|706 |Hospice beds |502 |Cobalt Unit |

| | |501 |CT Scanner |

|EXTENSION CLINIC |503 |Echo Cardiograph |

|Use the following listing for extension clinic proposals: |505 |Linear Accelerator |

|CON | |506 |Megavoltage Unit |

|CODES | |508 |Ultrasound |

|401 |Abortion O/P | | |

|491 |Alcohol Rehabilitation O/P |NON-MEDICAL FUNCTIONAL AREAS |

|402 |Ambulatory Surgery |Use these codes for all health care facilities to |

|451 |Audiology O/P |describe non-medical functional areas: |

| | |CODE |NON-MEDICAL SERVICES |

| | |901 |Administration (Routine) |

| | |902 |General Administration |

| | |903 |Admitting |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

|CODE |NON-MEDICAL SERVICES continued |980 |Other Functions |

|904 |Accounting/Financial Service |981 |Private Physicians Offices |

|905 |Administrative Personnel |982 |Housing on Call (Interns, residents, |

|906 |Data Processing | |physicians) |

|907 |Fund Appeal/Volunteers |983 |Housing Other (for parents of young |

|908 |Medical/Social Services | |patients, visitors, etc.) |

|909 |Energy Proposal |984 |Medically Related Computer |

|910 |Telephone System | | |

| | | | |

|920 |Public Areas | | |

|921 |Cafeteria | | |

|922 |Chapel/Meditation | | |

|923 |Lobby/Waiting/Public Entrance | | |

|924 |Coffee/Gift Shop/Flower/Canteen/Snack Bar | | |

| | | | |

|930 |Education/Research | | |

|931 |Supervising Physicians' Offices (Hospital | | |

| |physicians involved in research) | | |

|932 |Nursing School | | |

|933 |Medical Laboratory/Auditorium | | |

|934 |Research (Laboratory areas) | | |

|935 |Medical Teaching (for residents and interns; | | |

| |classrooms) | | |

| | | | |

|940 |Industrial/Service Functions | | |

|941 |Central Sterile and Supply | | |

|942 |Laundry/Linen | | |

|943 |Maintenance/Housekeeping | | |

|944 |Medical Supplies/Central Services/Storage | | |

|945 |Parking Structures (free-standing structures) | | |

|946 |Staff Lockers | | |

|947 |Tunnels, Bridges and Other Enclosed | | |

| |Circulation Spaces | | |

|948 |Equipment Maintenance (includes Biomedical | | |

| |Engineering Service) | | |

| | | | |

|960 |Building System | | |

|961 |Site Work (Replant grass, signs, etc.) | | |

|962 |On-site Parking, Excluding Garage Structure | | |

| |(parking lot) | | |

|963 |Outside Utilities (water, sprinkler, lights, | | |

| |outside sewer, etc.) | | |

|964 |Structure, Including Finisher (Paint building, etc.) | | |

|965 |Heating/Ventilation/Air Conditioning (HVAC) | | |

|966 |Sanitary System (Inner plumbing and ventilation) | | |

|967 |Electrical System | | |

|968 |Vertical & Horizontal Mechanized Movement | | |

| |(elevators, cart system) | | |

|969 |Fire Safety Equipment | | |

|970 |Communication System (Public address system) | | |

Limited Review Application

State of New York Department of Health/Office of Health Systems Management

SOLUTIONS/ACTIONS

This appendix lists the solutions/actions which should be used in describing your proposals.

When listing these solutions/actions in the application, do not include any descriptions inside parentheses.

|CODE |SOLUTIONS/ACTIONS | | |

|L |Add new medical equipment |5 |Expand existing space by new structure |

|M |Reduce existing medical equipment |6 |Relocation - reassign vacated space (within |

|N |Replace existing medical equipment 1 for 1 | |near term period) (Indicate proposed use in |

|O |Acquire/replace non-medical equipment | |a narrative) |

|1 |Minimal "in place" correction |7 |Relocation - vacated space remains unused |

|2 |Significant renovation (of existing space) |8 |Relocation - demolish vacated space |

|3 |Functional reassignment of spaces |9 |New construction |

|4 |Expand existing space within structure |10 |Acquire and/or renovate additional structure |

FACILITY TYPE

A Hospital F D&T Center

B Hospital/SNF G Long Term Home Health Care Program

C Hospital/D&T Center H Extension Clinic (D&T Center Sponsored)

D SNF I Extension Clinic (Hospital Sponsored)

E SNF/D&T Center J Central Service Facility

INSTRUCTION ON COMPLETING SCHEDULE 3

This schedule may be completed and signed by the applicant, a representative of the applicant, or by the applicant's architect, engineer or estimator.

Check the appropriate box at the top of the form to identify the reporting of new construction or alteration construction. If both types are involved, complete a separate schedule for each type. Enter the building number in column (1) and the floor number in column (2). Use Appendix A to complete Columns (3) and (4). This appendix lists the codes and functional categories for space distribution and groups them into sections. Any functional categories not listed in the appendix should be entered as 900 Other. When reporting building systems work, which is necessitated by work in a functional area/category and located outside this area, list the building systems work directly following the category and enter an asterisk (*) in column (5). The cost estimate in column (6) should be in first quarter dollars of the year the application is submitted. Column (7) Total Construction Cost = column (5) Functional Gross SF X column (6) Construction Cost/SF. Columns (5) and (7) should be subtotaled for each building. A sum of subtotals should be shown at the end of the report. Complete column (8) for alteration construction projects only. Enter either A, B or C for each functional category listed. Alterations are defined as:

A) Minor Alterations - Use of existing partitions, minor mechanical work

B) Medium Alterations - Some new partitions, half new mechanical work

C) Major Alterations - Gutting and rebuilding

-----------------------

|Total Project Cost |Schedule 1 |

|Proposed Plan for Project Financing |Schedule 2 |

|Space & Construction Cost Distribution |Schedule 3 |

Cover Sheet

Schedule 1

Schedule 2

Schedule 3

Appendix A

Page 1 of 4

Appendix A

Page 2 of 4

Appendix A

Page 3 of 4

Appendix A

Page 4 of 4

Appendix B

Appendix C

Appendix D

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download