NYC-WTC_000166105

NYC 9/11 Public Portal Document

Instructions to Inspectors--AII boxer , this form must have an answer. Answer ith 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 ~~z77~/~y C o-- Inspector______ r lc Name of Candidate_75U £-i2 ~~'~ Office Address ,'< ~( ~ ?"ate of Examination ?/ tr (Print last name, first name) Vie, /o& - Instructions to Inspectors—If any asterisk (•) items are marked "NO", terminate the test immediately. See Section Vill for YES NO N/A further information. I. Ph sical Re uirements—Does candidate have abili to: *A. Speak and understand English? B. Hear spoken words over a telephone? *C. Possess necessary vision? (with corrective devices) (corrective devices acceptable) Yes Li No❑ Yes Li No❑ Yes Li No❑ . ~ullulllu

Instructions to Inspector—If any violation (V) Items are marked "NO", Issue a Violation Order at the end of the Test. Test must proceed. II. Records: v. A. Fire dr t records current? v. B. Firemen1s-Service Elevator Test Records current? v. C. Keys k,9pt at Fire Command Station Yes No ❑ Yes "' No ❑ N/A ❑ Yes No ❑ N/A ❑ v. D. Fire Safety Plan and building floc v. E. A current list of all floor Wardens and phone v. F. Master window keys available? plan at Fire Command Station? num,Ps at Fire Command Station? ..- Yes 12' No Li Yes L No❑ Yes Li No❑ N/A L. 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 fl floo~properly numbered? v. C. Is floor, mad gram osted? Yes _ No Yes YJ No ❑ Yes Jd 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 bank? Yes VI No ❑ N/A ❑ Yes a No ❑ N/A ❑ Yes Ll 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 Stairs" posted? unobstr d? posted afid current? Yes 0 No ❑ N/A ❑ Yes No ❑ Yes 0 No ❑ TOTAL (9) Ill. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection FL OR v. A. Are sta'p4ys properly lettered? v. B. Are floo roperly numbered? v. C. Is floor gram posted? Yes No ❑ Yes No ❑ Yes No v. D. Are sta' ays re-entry v. E. Are elevators properly lettered on each v. F. Is floor diagram properly oriented? s1 n osted? elevator ank? YesV1 No ❑ N/A ❑ Yes No ❑ N/A ❑ Yes No [A v. G. Is elevator ign "In Case of Fire, v. H. Are exit doors unlocked, closed and v. 1. Fire Drill Organization Charts Use Sta' posted? unobstr ted? posted and current? Yes No❑ NIA❑ _Yes kl NoL Yes No LI 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: Le ,xi NAME OF FLOOR WA 13~si— EN CONTACTED L FLOOR CHOSEN . Y3 TELEPHONE NUMBER Does Floor Warden have knowled a of: A. Position uring fire drill or emergency? B. Notificatjon procedures? C. Location of alarm boxes? Yes l f No ❑ Yes 1 No ❑ I Yes 2' No ❑ N/A ❑ D. Evacuapf location? E. Evacu^ati~o procedures? F. Number exits on floor? G. Examining for exits on floor? Yes No ❑ Yes lam" No ❑ Yes No Li Yes No U H. Reporting-whether smoke or Fire? I. Duties o Depu,-ttY Fire Warden and Searchers? v. J. Were fire drills conducted? Yes ~No ❑ Yes L No Li Yes. No ❑ * K. Floor wardens in numerous floors properly trained? Yes No ❑ TOTAL (11) Section B: (II, 111, IV) a 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 16-H702503R25-P

NYC-WTC 000166154