Nebraska Department of Health and Human Services Pre-Construction Form

Pre-Construction requires the submission of the information requested below as well as an attached signed copy of the Architect/Engineer Plan Certification Form AND submission of the signed Construction plans on CD to the DHHS Facility Construction Office.

Facility/Pending Facility Name Required

Facility/Pending Facility Address (City/Street/County) Required

Facility/Pending Facility Type Required

Project/Phase Name (NOTE: Names must match on all documentation for both PRE- and POST-Construction) Required

Is this project a single-phase project or a multi-phase project? Required

If the project is a multi-phase project, please provide a name for each phase, along with a brief description of each phase
(Example: Phase 1: Bathroom Renovation 2W; Phase 2: Nurses Station Renovation 5E)

Project Type Required

Project Notification Information (Provide a brief but detailed description of the project. Example: Is this a replacement facility? Is this renovation for an existing facility? Will this result in an increase in beds/rooms?) Required

Will this project affect current patients/clients? Required

IF yes, please describe how the facility will continue to accommodate the patient/client needs during construction and ensure the licensure regulations for the facility will continue to be met during this project

Facility project contact person (Person to contact if the Department has questions or needs clarification. This must be a facility staff person)

Name Required

Email Address Required

Phone Required

I have submitted the Construction plans to DHHS Facility Construction on CD or flash drive. Required

DHHS Facility Construction
PO Box 94669
Lincoln, NE 68509-4669

Construction plans may also require separate submission to the State Fire Marshal’s office and a plan review by their office.

I have reviewed their website: https://sfm.nebraska.gov/plans/plans-submittal Required

Please upload and attach the following document:

Attachments - Total file size for all files cannot exceed 17 MB. Pdf, doc, docx, jpg, png, gif, and tiff formats are preferred.

Architect/Engineer Plan Certification Form
Required

Printed name of facility person submitting information Required

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