NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes Yl this form must have an answer. Answers^ 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—OFFI
Z 01 Inspector
4ame of Candidate^!:!;^^/E:?^^::^^__Z^Z^^^/^8^e Address _____________ Date of Examination
(Print last name, firs, name) 71/ ^ 7/394^
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terniinate the rest immediately. See Section VIII for YES NO N/A
further information.
I. 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) (correctiv^evices acceptable)
Yes No □ Yes No □ Yes [14'^No □
Building______
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 dn^ecords current? V. B. Firemen^ervicf irvice Elevator^Test Records current? v. C. Keys l«pt at Fire Command Station?
Yes No □ Yes No □ N/A □ Yes 0*^ No □ N/A □ 3
V. D. Fire Safety Plan and building floor V. E. A current list of all floor Wardens and phone v. F. Master window keys available?
plan at Pipe Command Station? numbers^at Fire Command Station?
Yes No □ Yes [B No □ Yes □ No □ N/A 0*^
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.
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for the general floor inspection
FLOOR
Building Inspection—Signs and Charts—
V. A. Are staip^ays properly lettered? V. B. Are floors properly numbered? V. C. Is floor dipgramposted?
Yes No □
V. D. Are stairways re-entry
Yes No □
V. E. Are elevators properly lettered on each
Yes No □
V. F. Is floor diagram properly oriented?
3
si^^osted? elev^r fhk?
Yes tY No □ N/A □
V. G. Is elevator sign “In Case of Fire,
Yes CB No □ N/A □ Yes No □
V. I. Fire Drill Organization Charts
3
V. H. Are exit doors unlocked, closed and
Use Stai^ posted?
Yes QIZ No □ N/A □
unobstru^d?
Yes^O-^No D
posted an;Lcurrent?
Yes No □ 3
TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
V. A. Are staipways properly lettered? V. B. Are floor^roperly numbered? V. C. Is floor diergram posted?
Yes □ No □ Yes 13^ No □ Yes Er No □ 3
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
si^s posted?
Yes No □ N/A □
elevator bank?
Yes noQ N/A □ Yes No □ 3
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? unobstrueted? posted apd current?
Yes 3^ No □ N/A □ Yes No □ Yes No □ J
_________________________________________________________________________________ ____________________ 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
// r/v
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position<during_fire drill or emergency? B. Notificatiph procedures? C. Locatioi alarm boxes?
Yes B No □ Yes No □ Yes B No □ N/A □
D. EvacuatkSn location? E. Evacuatiop procedures? F. Number of^its on floor? G. Examining for exits on floor?
Yes EJ No □ Yes [3/ No □ Yes LIL^o □ _____ Yes«Q^ No □__________
H. Reporting'whether smoke or Fire? 1. Duties of Deputy Fire Warden and Searchers? V. J. Were fii^rills conducted?
Yes □ No □ Yes No U Yes No □
*K. Floor wardens in numerous floors properly trained? Yes ES-'^o EZI /
Section B: (II, III, IV) 8 or mofg^apStwered “NO” in Section B fails.
TOTAL (11)
SECTION B TOTAL (36)
zZ
Number of correct answers in this sectictn is Number of incorrect answers is Number of N/A answers is
25-14 1&B70250-3-R25-P
NYC-WTC_000168823
OCR can misread numbers and units. Confirm readings against the page image before using them.