State of Delaware
Office of Health Facilities Licensing and Certification
(302) 995-8521
Application for Blueprint Review
 
I.  IDENTIFYING INFORMATION:

OHFLC PROJECT CODE ________________________________________________________

FACILITY NAME _____________________________________________________________
                                          Print

FACILITY ADDRESS __________________________________________________________
                                        ADDRESS 1

		 __________________________________________________________
                                        ADDRESS 2

		 ________________________________ ____________ ____________
                               CITY                  STATE       ZIP CODE


OWNER _____________________________________________________________________
                                          Print

      ___________________________ ____________________ ____________________
                 EMAIL                PHONE NUMBER             FAX


ARCHITECT _________________________________________________________________
                                          Print

          ___________________________ __________________ __________________
                     EMAIL               PHONE NUMBER            FAX
              

PRIMARY CONTACT ___________________________________________________________
                                        Print Name

RELATIONSHIP TO 
OWNER
                ___________________________________________________________
                                          Print

                _________________________ ________________ ________________
                          EMAIL             PHONE NUMBER         FAX


II.  FACILITY TYPE ________________________________________________________
                                          Print Name


III.  REGULATORY DETAILS

		CIRCLE: 	LICENSED		CERTIFIED		BOTH

IV.  SCOPE OF PROJECT
		
		CIRCLE:		1)  NEW FACILITY

				2)  NEW AREA OR SERVICE IN EXISTING FACILITY

				3)  UPDATE OR UPGRADE TO EXISTING AREA/SERVICE

				4)  USAGE CHANGE OF AN AREA

				5)  COSMETIC CHANGES

V.  	ATTACH A SHORT PROJECT DESCRIPTION TO ENABLE OHFLC TO IDENTIFY THE APPROPRIATE 
	SECTIONS OF THE 2006 Guidelines for Design and Construction of Health Care Facilities.

VI.  	PLEASE INDICATE WHAT SECTION(S) OF THE 2006 Guidelines for Design and Construction of 
	Health Care Facilities you are requesting authorization to utilize.  You must complete this 
	section or your application will be returned.

VII.	IF SURGICAL FACILITY OR HOSPITAL OPERATING ROOMS, COMPLETE THE FOLLOWING:


#  OF CLASS A ORS/PROCEDURE ROOMS  	__________


#  OF PREP/RECOVERY BEDS (DUAL USE)	__________


#  OF CLASS ENDOSCOPY ROOMS 		__________


#  OF PREP BEDS				__________


#  OF CLASS B OPERATING ROOMS 		__________


#  OF RECOVERY BEDS			__________


#  OF CLASS C OPERATING ROOMS		__________


TOTAL NUMBER OF OPERATING ROOMS		__________


VIII.  SIGNATURE OF PERSON COMPLETING THIS APPLICATION AND DATE


______________	________________________________________
DATE		Signature


**********************************************************************************************************
Reviewed and returned by OHFLC:


______________	________________________________________
DATE		Signature
Comments:





**********************************************************************************************************
Accepted by OHFLC:


______________	________________________________________
DATE		Signature
Comments:

Doc. # 35-05-20/07/06/14 
BP submission directions			2007