NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes|Blhis form must have an answer. Answers a “NO” answers to a “V” mandate a
Violation Order, “NO” answers to a mandate automStic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Inspector.
Name of Candidate
(Print last name, first name)
Office Address 'ate of Examination
z <
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terminate the test immediately. See Section VIII for YES NO N/A
further information.
I. Physical Requirements—Does candidate have ability to:
*A. Speak andLmderstand English? * B. Hear spokejpwSrds over a telephone? *C. Possess necessary vision?
(with CQp«6tive devices) (correctivp^aevices acceptable)
Yes No □ No □ YeS'ET 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 d^ ^ords current?
Yes lJ / No □
V. B. Firemi
Service Elevator Test Records current? v. C. Keys ki
No □ N/A □
YesE Ye!
at Fire Command Station?
No □ N/A □
V. D. Fire §gfety^an and building floor V. E. A current Kst of all floor Wardens and phone V. F. Master wii
numbejx^ Fire Command Station?
keys available?
3
plan at Fife Command Station? /
Yes EZ No □ Yes.0 No □ Yes No □ N/A
V. G. Buildfng current in actual Fire Drills? pygr 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:
'^F^OOR
Special Instructions—Choose one floor for the general floor inspection
Building Inspection—Signs and Charts—
V. A. Are Airways properly lettered? V. B. Are fjsjef^ properly numbered? V. C. Is floor-dfSgrarri posted?
Yes □ >lo □ )Sbs-Q No □ Yes-Q No □
V. D. Are stpifways re-entry V. E. Are elevi properly lettered on each V. F. Is floor diagram properly oriented?
signs'^osted? elevateflbank?
Yes □ No □/ N/A □ YeEU No □ N/A □ Yej No □
V. G. Is elevatofz^gn “In Case of Fire, V. H. Are exit di unlocked, closed and v. I. Fire Drill Organization Charts
Use St^" posted? unobstryel ed? posted anjl-turrent?
Yes>0 No □ N/A □ Yes^B””^ No □ Yes D^No □
TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
_____________ Zf______________________________ 7___________________________
V. A. Are stak^vays properly lettered? V. B. Are fjop0properly numbered? V. C. Is floordjsgfam posted?
Yes zWo □ No □ YepJEr No □
V. D. Are tirways re-entry V. E. Are elevalefs properly lettered on each V. F. Is floor dj^gr^ properly oriented?
sign losted?
Yes-0 No □ ^N/A □
elev^tor^ank?
V. G. Is elevator sjgfi ““In Case of Fire,
□ No □ N/A Qx
V. H. Are exit di unlocked, closed and
Y«<TJ No □
V. I. Fire Drill OrgarjizStion Charts
.£
Use Stair^Zposted?
Yes No □ N/A □
unobst^
Ye»Ej ■ No □
posted anjJzCtjrrent?
Y^s^P^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. /
i
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 WARDI
NAME OF FLOOR WARDEN CONggjtb FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position dywn^re drill or emergency? B. Notificayon-procedures? C. Loc^im )f alarm boxes?
Yes B‘'’”No 13 -Yes U No □ YesO No □ N/A □
D. EvacuatipB-iocation? E. EvagjjattSn procedures? F. Numberpt-elots on floor? G. Examininigjef exits on floor?
4E
Yes Ej No □ WsU No □ Yes No □ Yes-0^ Mo □
H. Reporting^ether smoke or Fire? I. Duties ofJ3eputy Fire Warden and Searchers? V. J. Were fi^dpi Is conducted?
Yes CHNo □ Yesjd"""^ No □ Yes-B"^No □
* K. Floor wardens in numerous floors properly trained? Yes □ ^Wo Q
TOTAL (11)
Section B: (II, III, IV) 8 or more answered “NO” in Section B fails. SECTION B TOTAL (36)
Number of correct answers in this section is Number of incorrect answers is Number of N/A answers is
,A25-14 16-37025O-3-R25-P
NYC-WTC_000168825
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