This chapter ensures all NIH facilities are designed and constructed in compliance with the International Building Code (IBC), the National Fire Codes, the NIH Design Requirements Manual, and other nationally recognized codes and standards (e.g., The Joint Commission standards for the accreditation of the NIH hospital), as required by 40 U.S.C. Section 3312, “Compliance with Nationally Recognized Codes.”

This chapter applies to NIH facilities located at the NIH Bethesda, Maryland; NIH Animal Center (NIHAC), Poolesville, Maryland; Frederick National Laboratory for Cancer Research, Frederick, Maryland; National Institute of Environmental Health Sciences (NIEHS), Research Triangle Park, North Carolina; and Rocky Mountain Laboratories (RML) Hamilton, Montana campuses. This chapter does not apply to NIH leased space and facilities. Leased facilities occupied by NIH employees but located outside DFM's jurisdiction are subject to the permit requirements of the local and/or state authority having jurisdiction. 

Proper fire protection and life safety is ensured in construction projects, renovations, or major equipment installations through oversight by the local fire safety “Authority Having Jurisdiction” (AHJ) at various stages of the project. The NIH Division of the Fire Marshal (DFM), Office of Security and Emergency Response (SER), Office of Research Services (ORS), as the designated AHJ for all fire-safety matters at the NIH, accomplishes this mission through: (1) design reviews, (2) fire protection construction submittal reviews and (3) construction inspections, both in-progress and at the completion of the project.

This chapter establishes the requirements for obtaining the fire protection and safety permits before beginning any construction, renovation, alteration, major equipment installation, or change of occupancy/use of the space in all NIH-owned facilities covered in B. Scope above.

The procedures in this chapter must be followed before work commences for any and all covered projects. Specific fire protection requirements for the design or planning phase, the construction phase, and the project completion phase are outlined in Appendices 1 - 5.

Violations of this policy may result in disciplinary action, the severity of which will vary depending upon the nature of the infraction.

1. The Director, Division of the Fire Marshal will:

1. Serve as the designated local fire safety AHJ for the NIH regarding all fire safety matters in any NIH facilities listed in Section B. Scope above. In the absence of the Director, he/she may designate another senior DFM staff member to serve as the AHJ. The AHJ is responsible for granting approval before any construction, renovation, alteration, major equipment installation, or change of occupancy/use of space is begun in any NIH facilities.
2. Review all required documentation for granting appropriate permits before any construction, renovation, alteration or major equipment installation is begun. Examples of such documentation are design documents, Statements of Work, and fire protection construction submittals for construction, renovation, or major equipment installations in accordance with Section G of this chapter.  The DFM will complete reviews within 14 calendar days from the date the complete package is received.  If any part of the package is disapproved, the DFM will provide a reason to support this determination.
3. Conduct pre-occupancy/final inspections for compliance with the International Building Code, the National Fire Codes, and the NIH Design Requirements Manual in accordance with Section G of this chapter.
4. Establish and maintain fire safety policies and procedures for the NIH.
5. Assess and enforce equivalent fire protection systems or measures in existing facilities when activities for construction create code deficiencies.

2. The Office of Research Facilities Development and Operations (ORFDO) will:

1. Submit design documents, Statements of Work, and fire protection submittals for renovation, construction, alteration, or major equipment installation projects to DFM for review and approval in accordance with Section G of this chapter.
2. Ensure IC and OD Offices do not occupy newly constructed or renovated space prior to having the DFM conduct a pre-occupancy/final inspection in accordance with Section G.

3. All Institutes/Centers (IC) and Office of the Director (OD) Offices will:

1. Submit for DFM review and approval design documents, Statements of Work, and fire protection construction submittals for construction, renovation, alteration or major equipment installations in accordance with Section G.
2. Ensure they do not occupy newly constructed or renovated space prior to having the DFM conduct a pre-occupancy/final inspection in accordance with Section G.

1. Design or Planning Phase

Any NIH organization engaged in construction, renovation, alteration, major equipment installation, or change of occupancy/use of the space, must submit design and/or planning drawings, specifications, and Statements of Work to the DFM for review. The following submissions are based on the size and scope of the project as described below:

1. Projects having an estimated cost of over $25,000

All design submissions must be reviewed by the NIH DFM. 

1. All final design submissions must be reviewed and approved by the NIH DFM prior to being released for procurement. Design Build projects shall consult the DFM prior to obtaining a Request for Proposal.
2. Only DFM approved final design documents may be used on the construction site. DFM final design approval will consist of a signed stamp on the cover sheet of the final design documents.
3. Per the NIH Facilities Development Manual, all designs for new structures (including designs for new wing additions or other additions to existing structures that modify the height and area or change the use group) must have a “Fire Protection Engineering Analysis” performed by a registered Fire Protection Engineer at the concept and final design phase.
4. The review and approval process are valid for only one year. Thus, a previously approved project that has not been activated for more than one year must be reviewed again by the DFM to ensure compliance with current codes and the NIH Design Requirements Manual before it is approved for release. Reviews of previously approved projects will be expedited and completed within 7 calendar days from the date the complete review package is received by the DFM. If the design documents are disapproved by the DFM, the DFM will provide a reason to support this determination.
5. If a design is amended during the pre-award period, the DFM must review the scope of the amendment and provide written verification that the amendment does not adversely impact fire protection or life safety and will not result in a code compliance issue. To assist the Project Officer in complying with this policy, a list of the usual project elements reviewed by the DFM to ensure code compliance is included in Appendix 1.

2. Projects having an estimated cost of under $25,000
   1. All final design documents requiring a DFM review must be reviewed and approved by the DFM prior to procurement.
   2. Only the DFM approved final design documents may be used on the construction site. DFM final approval will consist of a signed stamp on the cover sheet of the final design documents.
   3. The design documents must be reviewed by the DFM if the project includes any of the project elements described below:
      1. Change in occupancy/use of the space. The DFM will ensure compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code and verify existing fire protection features are appropriate;
      2. Construction, demolition or removal of walls. The DFM will ensure compliance with the NFPA 101 Life Safety Code and will determine any impact on sprinkler systems;
      3. Removal or installation of doors. The DFM will ensure compliance with the NFPA 101 Life Safety Code and will determine if any doors must be fire rated;
      4. Relocation, removal or installation of sprinklers and standpipes. The DFM will ensure compliance with NFPA 13, Standard for the Installation of Sprinkler Systems and NFPA 14, Standard for the Installation of Standpipe and Hose Systems;
      5. Relocation, removal or installation of fire alarm devices. The DFM will ensure compliance with NFPA 72, National Fire Alarm Code;
      6. Penetration of walls or floors. The DFM will determine if required fire barriers are being penetrated and if fire stopping is required;
      7. Installation, removal or relocation of equipment (i.e. Heating Ventilating and Air Conditioning equipment, piping, furnishings, furniture, etc.). The DFM will determine if existing fire protection features are adversely impacted.

2. Construction Phase
   1. Change Orders: Any organization including but not limited to the ORFDO, the Center for Information Technology (CIT) or other IC engaged in construction, renovation, alteration or major equipment installation, must submit any proposed change order affecting the project elements identified in Appendix 1 to the DFM for review.  Change order reviews will be expedited and completed within 7 calendar days from the date the complete change order package is received by the DFM.  If the change order is disapproved, the DFM will provide a reason to support its determination.
   2. Required Fire Protection Construction Submittal Reviews: Any organization including but not limited to the ORFDO, the Center for Information Technology (CIT) or other IC engaged in construction, renovation, alteration or major equipment installation, must submit the required fire protection construction documents concerning the project elements outlined in Appendix 2 to the DFM for review and approval.
      1. All fire protection construction submittals must be reviewed and approved by the DFM prior to installation; and
      2. Only the DFM approved fire protection construction submittals including but not limited to sprinkler and fire alarm shop drawings can be used on the construction site.  The DFM fire protection construction submittal approval will consist of a signed stamp on the cover sheet of the shop drawings and/or product data.
   3. Required In-Progress Construction Inspections:
      1. Any organization including but not limited to the ORFDO, the Center for Information Technology (CIT) or other IC engaged in construction, renovation, alteration or major equipment installation must request DFM inspections for all projects that contain any of the project elements outlined in Appendix 3.  These items must be inspected prior to "close-in;" and
      2. Depending on the scope of the project, there may be many "in-progress" inspections before the final inspection.
   4. Required Fire Protection System Inspections and Acceptance Tests: Any organization including but not limited to the ORFDO, the Center for Information Technology (CIT) or other IC, engaged in construction, renovation, alteration or major equipment installation must request DFM inspections for all projects which contain any of the project elements outlined in Appendix 4. These items must be inspected and tested prior to scheduling a final inspection of the entire project.
3. Project Completion Phase
   1. Required Fire Protection Pre-Occupancy/Final Inspection: Any organization including but not limited to the ORFDO, the Center for Information Technology (CIT) or other IC engaged in construction, renovation, alteration or major equipment installation must obtain a DFM pre-occupancy/final inspection approval memorandum for all projects, prior to final payment to the construction contractor. See Appendix 5.

1. International Building Code (IBC) (https://codes.iccsafe.org/public/document/IBC2018) : Available in hard copy in DFM, ORS.
2. National Fire Protection Association (NFPA), National Fire Codes: Available in hard copy in DFM, ORS. Viewable online at https://www.nfpa.org/Codes-and-Standards/All-Codes-and-Standards/Free-access
3. NIH Design Requirements Manual (NIH DRM)  or PDF (https://www.orf.od.nih.gov/PoliciesAndGuidelines/Documents/DRM/DRM1.2120718.pdf) 
4. NIH Manual Chapter 1743, "Keeping and Destroying Records," Appendix 1, NIH Records Control Schedule: https://policymanual.nih.gov/1743  
5. NIH Facilities Development Manual

1. Authority Having Jurisdiction (AHJ): An organization, office or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation, or a procedure. At the NIH, the AHJ for fire protection and safety has been designated as the NIH Division of the Fire Marshal (DFM), Office of Research Services (ORS).
2. Design Review: The process of review and approval of the scope of work, plans and specifications for construction, alteration and renovation.
3. Fire Protection Construction Submittal Review: The process of reviewing drawings, calculations and material data for fire protection related system and equipment installations.
4. Major Equipment Installation: The installation of a new piece of equipment that may have an adverse impact on existing features of fire safety.  Examples are: Equipment that requires a new penetration be made through existing fire rated walls and/or floors for piping and conduit; equipment that may impair or block existing sprinkler protection due to the size and/or location; and equipment that may increase noise to a level where the existing fire alarm devices may no longer be heard.
5. Nationally Recognized Testing Laboratories (NRTL): An organization that is acceptable to the AHJ and that evaluates products or services and that periodically inspects production of listed equipment or materials or periodic evaluation of services. The NRTL issued listing states that the equipment, material, or service meets appropriate designated standards or has been tested and found suitable for a specified purpose.
6.  Use Group - A model building code term that is used to indicate use and occupancy classification for all buildings and structures (e.g. business, industrial, storage, etc.)
7. Sheet Metal and Air Conditioning Contractors National Association (SMACNA®): An international association of union contractors with 103 chapters throughout the United States, Canada, Australia and Brazil that specialize in heating, ventilating and air conditioning; architectural sheet metal; industrial sheet metal; kitchen equipment; specialty stainless steel work; manufacturing; siding and decking; testing and balancing; service; and energy management and maintenance.

All records (e-mail and non-e-mail) pertaining to this chapter must be retained and disposed of under the authority of the NIH Manual Chapter 1743, "Keeping and Destroying Records", Appendix 1: Records Control Schedule; and NIH General Records Schedule

The purpose of this chapter is to provide guidance to NIH personnel for obtaining the required NIH Division of the Fire Marshal approvals before beginning any construction, renovation or major equipment installation projects.

1. Office Responsible for Reviewing this Chapter: Through this manual issuance, the DFM is responsible for ensuring that internal controls are implemented and working.
2. Frequency of Review: Ongoing.
3. Method of Review:  The DFM will maintain oversight and ensure compliance with this policy by assessing documentation obtained through their routine fire protection and life safety surveys of NIH facilities, monitoring DFM monthly performance data in conjunction with the ORFDO project status database.
4. Review Reports: Reports are sent to the Director, ORS; Director, ORFDO; and the Deputy Director for Management, NIH. Issues of special concern will be brought immediately to the attention of the Director, ORS.