NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors—All boxes this form must have an answer. Answert th a "NO" answers to a "V" mandate a Violation Order, "NO" answers to a "*" mandate automatic failure. Check "YES" "NO" or "N/A". ON SITE EXAM FOR FIRE SAFETY DIRECTOR-OFFICE Z 01 ~` Y1/ 7 Z J inspector_______ Name of Candidate `~ /thcTc' -Office Address / 1 Lf C. /u C( /t ! ate of Examination (Print last name, first name) /7 Z A: — Instructions to Inspectors—if any asterisk (*) items are marked "NO", terminate the test immediately. See Section VIII for YES NO N/A further information. 1. Physical Requirements—Does candidate have ability to: *A. Speak and understand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision? (with corrective devices) (corrective devices acceptable) Yes IG No 0 Yes.2' No ❑ YesQ` No ❑ B: Buildina Instructions to Inspector—If any violation (V) items are marked "NO", Issue a Violation Order at the end of the Test. Test must proceed. 1I. Records: v. A. Fire dril records current? v. B. Fireme ' Service Elevator Test Records current? v. C. Keys ke at Fire Command Station'; i Yes 0 No ❑ Yes L No ❑ N/A ❑ Yes No ❑ N/A U v. D. Fire Safety Plan and building floe v. E. A current list of all floor Wardens and phonel v. F. Master window keys available? plan at a Command Station? numbs at Fire CommandStation? Yes li No❑ Yes k1 No❑ Yes❑ No❑ N/A X ] v. G. Building current in actual Fire Drills? * if over 3 months Yes No ❑ TOTAL (7) Instructions to Inspector—If any violation (V) Items are marked "NO", issue a Violation Order at the end of the Test. Test must Proceed. Ill. a. Specific Building Inspection: Special Instructions—Choose one floor for the general floor inspection / FLOOR Building Inspection—Signs and Charts— v. A. Are stairways roperly lettered? v. B. Are flo s properly numbered? v. C. Is floo iagram sted? Yes Z] No Yes Z No ❑ Yes _ No H v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? si s posted? elevator ank? Yes L No ❑ N/A ❑ Yes No ❑ N/A ❑ Yes _ No ❑ v. G. Is elevator sign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. I. Fire Drill Organization Charts Use 5.ttaJ's" posted? unobst cted? posted and current? Yesi,~ No❑ N/A❑ YesL No❑ Yes i No❑ J TOTAL (9) Ill. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FLOOR v. A. Are st ),ways properly lettered? v. B. Are tIooj properly numbered? v. C. Is floor gram posted? ..7 Yes No ❑ _Yesj4NoLI Yes ZI No ❑ v. D. Are stairways re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? Si posted? elevator ank? Yes 2 No❑ N/A❑ Yes(No❑ N/A❑ Yes# No❑ v. G. Is elevator sign "in Case of Fire, v. H. Are exit doors unlocked, closed an j v. I. Fire Drill Organization Charts Use S rs" posted? unob, cted? posted And current? Yes J No ❑ N/A ❑ Yes No ❑ Yeses No TOTAL (9) IV. Instructions to Inspector—If four (4) or more Items below are marked "NO", the inspector must issue a Violation Order at the end of the test. Test must proceed. This next part must proceed with contacting a Floor Warden within the Building. Read the following statement to the Warden-"In the event of a fire on this floor, explain which specific actions must be taken by you." FLOOR WARDENS:

NAME'Or FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER Does Floor Warden have knowled a of: _ A. Positior)• durin fire drill or emergency? B. Notifica ' n procedures? C. Location of alarm boxes? Yes No~ Yes J No ❑ j Yes 2 No U N/A ❑ D. Evacu on location? E. Evacu)Jpn procedures? F. Number exits on floor? G. Exaq jpg for exits on floor? Yes Jd o ❑ Yes No ❑ Yes V No ❑ Yes VT No ❑ H. Re orti whether smoke or Fire? I. DutiesS"De utt Fire Warden and Searchers? v. J. Were fire drills conducted? Yes No ❑ Yes kJ No LJ Yes No * K. Floor wardens in numerous floors properly trained? Yes No ❑ _ TOTAL (11) Section B: (11, Ill, IV) 8 or more answered "NO" in Section B falls. SECTION B TOTAL (36) Number of correct answers in this section is . Number of incorrect answers is . Number of N/A answers is M25-14 164P02503R25•P

NYC-WTC 000166153