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Facility Construction

Forms

 

 
NOTE: The facility as the licensee is responsible for submission of the following documents/information to the Facility Construction office prior to the start of construction and prior to receiving approval for the public to use the newly constructed area.  ALL forms for Pre-Construction or Post-Construction must be submitted at the same time.
 
PLEASE make sure all names match for the facility and project/phase prior to submission for Pre-construction and Post-Construction or your submission may be returned to you for resubmission. This may delay the approval process.

 PRE-CONSTRUCTION

  • Architect/Engineer Plan Certification Form This form is required for both electronic and postal submission. This form needs to be signed by a Nebraska licensed architect/engineer. This form is fillable and the architect/engineer can sign it digitally. 
     
  • Pre-Construction Project Information Form This form is only required for postal submission. This must be completed and submitted by the facility.

  • Construction Plans  These are required to be submitted to the Facility Construction Office on CD and may be required to be submitted to the State Fire Marshal’s office for plan review.  Please check the SFM website here.
     
  • Construction Waiver This form is only required when the facility wants to ‘waive’ a current physical plant requirement for the facility construction project they are submitting.

 POST-CONSTRUCTION 

  • Completion Certificate This form is required and needs to be completed and signed by a Nebraska licensed architect/engineer. This form requires some additional supporting documentation as outlined in the top section of the form.
      
  • Occupancy/Occupancy Permit This is a required document that needs to be completed by the State Fire Marshal’s office or delegated authority.  For a listing of delegated authority cities click here.
     
  • Floor plan/Schematic drawing This required document is a simple drawing identifying key areas of the facility, such as: hand washing stations, nursing stations, medication rooms, bathrooms, patient bathing facilities, fire stations and patient rooms.

  • Hospital Bed Count Form
  • Nursing Facility Bed Count Form
    This is only required when the facility bed count has changed as a result of this construction project.

  • Zoning Approval This is only required for any new facilities, buildings, and offsite locations that are not located in an already licensed or previously licensed facility. 

 

 

Mailing Address
Nebraska DHHS
Division of Public Health
Licensure Unit
PO Box 94986
Lincoln NE 68509

Physical Address
Nebraska State Office Bldg
301 Centennial Mall S
14th & M Streets
3rd Floor
Lincoln NE 68508
  
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which can be downloaded for free from Adobe Systems, Inc.
 
 
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