SOP #441: State-Mandated Life Safety System Impairment Reporting (ORC 3345.111)

1.0 Purpose and Scope

This Standard Operating Procedure (SOP) establishes the mandated process for identifying, documenting, and reporting life safety system impairments that reach or exceed 48 hours to the Ohio Department of Higher Education (ODHE) and the Department of Administrative Services (DAS), pursuant to Ohio Revised Code (ORC) Sec. 3345.111 (as enacted by House Bill 184).

This SOP compliments SOP #440 (Life Safety Impairment/High Risk Work Management) and applies to all university-owned or controlled existing facilities.

Applicable Systems Include:

  • Fire Alarm Systems
  • Fire Suppression Systems (Sprinkler, Standpipe, Special Hazard)
  • Building Emergency Generators supporting life safety systems
  • Other occupant life safety and monitoring systems subject to fire/building code compliance

2.0 Management Tool and System of Record

The TMA Work Order System serves as the sole official System of Record for tracking life safety system timelines, identification dates, active durations, and resolution timestamps.

  • Tracking: All active impairment work orders (assigned Task Code SF001 per SOP #440) that reach 36 hours of continuous downtime will trigger an automated alert on the Active Impairment Dashboard for the Environmental Health and Safety Office (EHSO).
  • Audit Trail: TMA work order logs will serve as legal proof of the timeline from initial system downtime identification to full system restoration and clearance.

3.0 Procedure for Extended Impairment State Reporting (>48 Hours)

3.1 Identification & Escalation

When an active life safety impairment reaches 48 hours, or when a planned/unplanned impairment is projected at onset to exceed 48 hours:

  1. The assigned Trade Shop Manager or Project Manager must immediately update the active TMA Impairment Work Order notes with the estimated total duration and required remediation steps including estimated cost for the remediation.
  2. The TMA system status will automatically escalate the record for EHSO State Reporting review.

3.2 EHSO State Reporting Preparation

The EHSO Safety Coordinator (or designated qualified staff) shall:

  1. Extract the timeline, scope, and plan of action details from the TMA tracking work order.
  2. Complete Form EHSO-FRM-441A: State Life Safety System Impairment & Plan of Action Notification.
  3. Include an estimated cost to conduct the remediation work as required by ORC Sec. 3345.111.

3.3 State Submission

  1. EHSO shall submit Form EHSO-FRM-441A via email to ODHE/DAS at BuildingInspection@highered.ohio.gov.
  2. Submission Window: The report must be submitted to the state as soon as the 48-hour mark is reached, and no later than seven (7) days from initial identification in accordance with state guidelines.
  3. A PDF copy of the submitted form and email confirmation must be attached to the primary TMA Impairment Work Order.

4.0 System Restoration & State Clearance Protocol

4.1 System Correction Verification

Upon completion of repair activities under the Execution Work Order:

  1. The Trade Shop Manager / Contractor must test and verify full restoration of the life safety system.
  2. The Trade Shop Manager updates and closes the Execution Work Order in TMA.

4.2 State Impairment Resolution Filing

Within 24 hours of system restoration for any state-reported impairment:

  1. EHSO completes Form EHSO-FRM-441B: State Life Safety System Impairment Resolution & Clearance.
  2. EHSO transmits Form EHSO-FRM-441B to BuildingInspection@highered.ohio.gov to formally update state records.
  3. The Safety Coordinator changes the status of the tracking WO in TMA to "Closed" and attaches the final clearance record.

 

5.0 Audit and Review

5.1 Quarterly State Reporting Audit

The Safety Coordinator shall audit 100% of all TMA work orders that exceeded 48 hours to ensure:

  • State notification (Form EHSO-FRM-441A) was submitted within the statutory 7-day window.
  • Cost estimates for remediation were properly documented and filed.
  • Resolution clearance (Form EHSO-FRM-441B) was filed upon work completion.

5.2 Annual Compliance Verification

An annual audit of all TMA impairment timestamps against state submission logs will be conducted to verify complete alignment and legal compliance with ORC Sec. 3345.111 requirements.

6.0 Reporting

The Safety Coordinator shall incorporate state reporting metrics into the quarterly life safety summary, including:

  • Total number of impairments exceeding the 48-hour threshold.
  • Average duration of state-reported extended impairments.
  • Total estimated and actual remediation costs associated with reported extended impairments.
  • Compliance rate of state filings made within the required 7-day timeline.

Related Documents, Forms, and Tools

Impairment Notification & Plan of Action Form

Impairment Clearance & Resolution Form

 

Revision History

Date

Revision Description

Author / Title

August 2026

Initial SOP Creation to comply with ORC Sec. 3345.111 / HB 184

Environmental Health & Safety Office

 

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