Worksheet 4.7.1: Cover sheet
Zone number and total zones, facility name and address, zone(s) evaluated, provider/vendor number, date of survey, surveyor and fire authority signatures, and additional comments.
CMS-2786T
Fire Safety Evaluation System - Health Care 2012 Life Safety Code
- Agency
- CMS
- Revision
- 02/2026
- Fillable fields
- 187
- Pages
- 7
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-2786T: Fire Safety Evaluation System for Health Care Facilities
Form CMS-2786T is the Fire Safety Evaluation System for Health Care Facilities from the Centers for Medicare & Medicaid Services. It is marked 2012 Life Safety Code and Form Approved OMB Exempt, and it is based on NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 Edition.
The form is a set of worksheets completed for each fire/smoke zone, which it defines as a space separated from all other spaces by floors, horizontal exits, or smoke barriers. Where conditions are the same in several zones, one set of worksheets can be used for those zones. Ten steps lead from a cover sheet through occupancy risk and safety scores to a conclusion on whether the level of life safety is at least equivalent to that prescribed by the Life Safety Code.
The cover sheet says CMS forms shall be completed and retained as part of the survey record. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-2786T
Worksheets 4.7.2 and 4.7.3: Occupancy risk
Five risk parameters: patient mobility (M), patient density (D), zone location (L), ratio of patients to attendants (T) and patient average age (A). Multiplying them gives the occupancy risk factor F.
Worksheets 4.7.4 and 4.7.5: Adjusted risk
The adjusted building status R: 1.0 x F for a building classified as New, 0.6 x F for Existing. The form says results are always rounded up.
Worksheets 4.7.6 and 4.7.7: Safety parameters
Thirteen safety parameters, from construction and interior finish to smoke detection and automatic sprinklers, scored and totaled into containment (S1), extinguishment (S2), people movement (S3) and general safety (S4).
Worksheets 4.7.8 and 4.7.9: Equivalency
Mandatory safety requirement values Sa, Sb and Sc by facility type and floor, then S1 minus Sa, S2 minus Sb, S3 minus Sc and S4 minus R, each marked Yes or No.
Worksheets 4.7.10 and 4.7.11: Facility checks and conclusion
Twelve facility fire safety requirements, A to L, each marked Met, Not Met or Not Applicable, then one of three written conclusions.
The form has seven pages of worksheets numbered 4.7.1 to 4.7.11.
How to fill out Form CMS-2786T
- 1
Complete the cover sheet
Step 1: fill in Worksheet 4.7.1 for the zone, or for several zones with the same conditions.
- 2
Score occupancy risk
Steps 2 and 3: circle one risk factor value for each of the five risk parameters, transfer them to Worksheet 4.7.3 and multiply to get F.
- 3
Compute R
Step 4: use Worksheet 4.7.4 for a building classified as New or 4.7.5 for Existing, round up, and transfer R to Worksheet 4.7.9.
- 4
Score the safety parameters
Steps 5 and 6: circle one value for each of the 13 parameters, choosing the lowest point value if two or more appear to apply, then add the four columns. The sprinkler value in the People Movement column is recorded as half.
- 5
Compare with the mandatory values
Steps 7 and 8: pick Worksheet 4.7.8A, 4.7.8B or 4.7.8C by facility type, classification and floor. In Worksheet 4.7.9, check Yes if the answer is zero or greater and No if it is negative.
- 6
Check the facility and conclude
Steps 9 and 10: complete one copy of Worksheet 4.7.10 for each facility, then mark one of the three conclusions in Worksheet 4.7.11.
The form numbers its own steps 1 to 10. They are grouped here.
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Records, scope and status
Keeping the form
The cover sheet says CMS forms shall be completed and retained as part of the survey record. The form does not print a mailing address.
One set per zone
The worksheets are completed for each fire/smoke zone. One set can be used for several zones with the same conditions. Worksheet 4.7.10 is completed once for each facility.
Code editions
The form is marked 2012 Life Safety Code and refers to NFPA 101A, Guide on Alternative Approaches to Life Safety, 2013 Edition.
OMB status and revision
The form is marked Form Approved OMB Exempt. It prints Form CMS-2786T (02/2026), and the CMS page lists a revision date of 2026-02-01.
Related forms
Who uses Form CMS-2786T?
The cover sheet has signature blocks for a surveyor and a fire authority. The mandatory safety worksheets name the facility types.
Official sources and the blank
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Questions about Form CMS-2786T
What is a fire/smoke zone on Form CMS-2786T?
The form defines it as a space separated from all other spaces by floors, horizontal exits, or smoke barriers.
Does every zone need its own worksheets?
The form says to complete the worksheets for each fire/smoke zone, but where conditions are the same in several zones, one set of worksheets can be used for those zones.
Which worksheet applies to an existing nursing home?
The form uses Worksheet 4.7.8B(1) for existing nursing homes that did NOT use the Fire Safety Evaluation System for compliance before July 5, 2016, and 4.7.8B(2) for those that did.
How is a result rounded?
In Worksheets 4.7.4 and 4.7.5, the form says results are always rounded up, for example 3.2 is rounded to 4.0.
What are the possible conclusions?
Worksheet 4.7.11 has three. Two say the level of safety is at least equivalent to NFPA 101, Life Safety Code, for health care occupancies. The third says it is not shown by this system to be equivalent.
Who signs Form CMS-2786T?
The cover sheet has signature lines for the surveyor and for the fire authority, each with title, office and date.
Does Form CMS-2786T have an OMB number?
No. The form is marked Form Approved OMB Exempt, and the CMS page lists the OMB number as Exempt.