NYC 9/11 Public Portal Document
VENTILATION SYSTEM EVALUATION FORM
Please complete this form in accordance with instructions in the accompanying guidance document
Part 1.0 General Information
Date of evaluation: Building contact name and phone:
Evaluation team (list name and affiliation):
(Environmental professional)
(HVAC professional)
Building address: Type of Facility (check all that apply):
23 Residential
23 Multi-use
23 Other (describe)
Date of construction:
Number of residential units: Number of floors:
Prior inspection report/maintenance records available for review?:
Other comments
Ventilation system types (check all that apply and indicate total no. of units)
LJ Central ventilation system LJ Mechanical exhaust system
Est. no. of units Est. no. of imits
r i Mechanical make-up air system [ 1 Passive shaft/duct
Est. no. of units Est. no. of imits
I 1 Other (describe)
I certify that to the best of my knowledge, the information and observations recorded on this form
including all attachments are a true and accurate representation of site conditions.
Ventilation System (HVAC) Evaluator Date
Part 2.0 Visual Inspection Forms
Use the attached forms to document visual inspections. Complete the forms in accordance with
instructions in the accompanying guidance document
NYC-WTC_000139866
OCR can misread numbers and units. Confirm readings against the page image before using them.