Form 443086 Project Submission Form for Ambulatory Surgical Treatment Center - Illinois

Form 443086 or the "Project Submission Form For Ambulatory Surgical Treatment Center" is a form issued by the Illinois Department of Public Health.

Download a PDF version of the Form 443086 down below or find it on the Illinois Department of Public Health Forms website.

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Project Submission Form for Ambulatory Surgical Treatment Center
Project identifying information
For IDPH Use only
All sections of this form must be completed. Altered forms will not be accepted
IDPH number________________
Facility name
Street address
IL
City
ZIP code
Project name (as it appears on the drawings)
Multi-specialty
Licensure category
Single specialty
GI
Laser
Pregnancy termination center
Type of project
New/replace facility
Renovation/update to existing facility
Addition to existing facility
Is this a phased project?
Yes
No
If yes, attach an occupancy schedule describing the rooms to be occupied in each phase with a small scale graphic plan.
Submission type
Provide one set of signed/sealed drawings and outline specifications for review in accordance with Section 250.2430 of the
Illinois Hospital Licensing Requirements. This includes design development drawings and outline specifications and
working/construction drawings and specifications. Drawing size may not exceed 30" X 42".
Design development drawings - 30-day review time after deemed complete
Working/construction drawings - 60-day review time after deemed complete
Revised drawings - 45-day review time after deemed acceptable
Additional/addendum drawings - 45-day review time after deemed acceptable
Certificate of need
Provide a copy of a valid certificate of need (CON) or written documentation from the Health Facilities Services and Review
Board that the project does not require a CON. A review by the Department WILL NOT begin until a CON or appropriate
documentation is received.
CON project number
Date approved
Mail completed submission to:
Design and Construction Section, Illinois Department of Public Health
525 W. Jefferson St., Fourth Floor, Springfield, IL 62761
For questions, call:
217-785-4264, 217-785-4247 or TTY 800-547-0466
Important notice The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Public
Act 90-0327. Disclosure of this information is mandatory.
Form Number 443086-rev 12-2017
Page 1 of 5
Project Submission Form for Ambulatory Surgical Treatment Center
Project identifying information
For IDPH Use only
All sections of this form must be completed. Altered forms will not be accepted
IDPH number________________
Facility name
Street address
IL
City
ZIP code
Project name (as it appears on the drawings)
Multi-specialty
Licensure category
Single specialty
GI
Laser
Pregnancy termination center
Type of project
New/replace facility
Renovation/update to existing facility
Addition to existing facility
Is this a phased project?
Yes
No
If yes, attach an occupancy schedule describing the rooms to be occupied in each phase with a small scale graphic plan.
Submission type
Provide one set of signed/sealed drawings and outline specifications for review in accordance with Section 250.2430 of the
Illinois Hospital Licensing Requirements. This includes design development drawings and outline specifications and
working/construction drawings and specifications. Drawing size may not exceed 30" X 42".
Design development drawings - 30-day review time after deemed complete
Working/construction drawings - 60-day review time after deemed complete
Revised drawings - 45-day review time after deemed acceptable
Additional/addendum drawings - 45-day review time after deemed acceptable
Certificate of need
Provide a copy of a valid certificate of need (CON) or written documentation from the Health Facilities Services and Review
Board that the project does not require a CON. A review by the Department WILL NOT begin until a CON or appropriate
documentation is received.
CON project number
Date approved
Mail completed submission to:
Design and Construction Section, Illinois Department of Public Health
525 W. Jefferson St., Fourth Floor, Springfield, IL 62761
For questions, call:
217-785-4264, 217-785-4247 or TTY 800-547-0466
Important notice The state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Public
Act 90-0327. Disclosure of this information is mandatory.
Form Number 443086-rev 12-2017
Page 1 of 5
Project Submission Form for Ambulatory Surgical Treatment Center
Estimated project cost
1. Site preparation costs
$
2. Demolition costs
$
3. Construction contracts (including cost of materials)
$
4.
Subtotal - lines 1 thru 4
$
5. Fixed capital equipment*
$
6.
Total - lines 4 and 5
$
If line 5 is not 51 percent or more of line 6, then use line 6 for the plan review fee calculation below.
7. If line 5 is 51 percent or more than line 6, then multiply line 5 by .20
$
8.
Add lines 4 and 7: this is your adjusted estimated project cost
$
Place the total adjusted estimated project cost in the appropriate estimated project cost category listed below.
*Fixed capital equipment is any equipment that is not movable from room to room and includes but is not limited to
diagnostic equipment (MRI,scanners, X-ray equipment, etc). Equipment which is part of the building such as AHU, boilers,
chillers, lights, fire alarm panels and all related components are to be included in the construction costs.
Plan review fee calculation
The plan review fee is due and payable upon submission of this form along with the drawings and required information. Using the
figures in line 5, calculate the plan review fee.
Estimated project cost
Fee as listed below
Less than $100,000
No fee
$100,000 - $499,999
or $2,400, whichever is greater
x .012 =
Project cost
$500,000 - $999,999
or $6,000, whichever is greater
x .0096 =
Project cost
$1,000,000 - $4,999,999
or $9,600, whichever is greater
x .0022 =
Project cost
Greater than $5,000,000
or $11,000, whichever is greater; maximum fee of $40,000
x .0011 =
Project cost
Plan review fee to be submitted $
emittance should be made payable to the IDPH Plan Review Fund in the form of a check or money order.
R
Form Number 443086-rev 12-2017
Page 2 of 5
Project Submission Form for Ambulatory Surgical Treatment Center
Code analysis information for EXISTING BUILDING for a renovation/remodel project
Circle all that apply:
I(443)
I(332)
II(222)
II(111)
II(000)
III(211)
III(200)
V(111)
V(000)
Year built
Number of stories
Height in feet
Full
Partial
Dry
Wet
None
Sprinkler system
Fire pump capacity
Water main size
Emergency power
Type
Generating set
UPS
Other
Fuel storage in gallons
Fire alarm
Direct F.D. connection
Remote station
Proprietary protective
Coded
Supervisory
Code analysis information for NEW CONSTRUCTION of a new building or addition to the existing building.
Construction type per NFPA 220 for the new construction. Complete the code analysis information on the existing
building that the new construction is connected to or adjacent to under EXISTING BUILDING.
Circle all that apply:
I(443)
I(332)
II(222)
II(111)
II(000)
III(211)
III(200)
V(111)
V(000)
Number of stories
Height in feet
Structural component
Assembly rating
UL assembly number
Roof
Floor
Beams
Columns
Girders
Interior walls
Exterior walls
Full
Partial
Dry
Wet
None
Sprinkler system
Fire pump capacity
Water main size
Emergency power
Type
Generating set
UPS
Other
Fuel storage in gallons
Fire alarm
Direct F.D. connection
Remote station
Proprietary protective
Coded
Supervisory
Form Number 443086-rev 12-2017
Page 3 of 5
Project Submission Form for Ambulatory Surgical Treatment Center
Functional program narrative
Provide a functional program narrative for the project that describes the purpose of the project, departmental relationships,
space requirements and other basic information relating to fulfillment of the facility's objectives. The functional program
narrative shall include a description of those services necessary for the complete operation of the facility. The functional
program narrative must be available for use in the development of project design and construction documents.
Attach additional sheets if needed.
Systems program narrative
Provide a systems program narrative describing all special systems including, but not limited to, fire alarm, nurses call,
special locking devices, security packages, electrical, plumbing, HVAC, medical gas and fire protection.
Attach additional sheets if needed.
Form Number 443086-rev 12-2017
Page 4 of 5
Project Submission Form for Ambulatory Surgical Treatment Center
Contact Information
Name of facility representative
Title
Facility/Organization
Address
City
ZIP code
State
Phone number
E-mail address
Architectural firm
Address
City
ZIP code
State
Phone number
Name of architect of record for the project licensed in State of Illinois
E-mail address for architect of record
Illinois license number
Illinois State Fire Marshall license number
Sprinkler contractor
Address
City
State
ZIP code
Contact name
Phone number
E-mail address
HVAC design firm
Address
City
ZIP code
State
Contact name
Phone number
E-mail address
Electrical system designer
Address
City
ZIP code
State
Contact name
Phone number
E-mail address
Fire alarm company
Address
City
ZIP code
State
Contact name
Phone number
E-mail address
Form Number 443086-rev 12-2017
Page 5 of 5

Download Form 443086 Project Submission Form for Ambulatory Surgical Treatment Center - Illinois

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