NYC 9/11 Public Portal Document
Instructions to Inspectors—All box^Sin this form must have an answer. Answi ith a “NO” answers to a “V” mandate a
Violatior^U
rder, “NO” answers to a mandate automatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
.y Z 0 1 ______________________________ Inspector_______ _________ ________
Name of Candidate/r^*^^^**^^^^ Office Address of Examination
(Print las/name, first name)
(
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 yr
*A. Speak /nd understand English? * B. Hear spoken words over a telephone? * C. Possess necessary vision?
(withk^rrective devices) (correcUVe devices acceptable)
YesyO No □ Ye<lJ No □ Yes/Q 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 dri)i4ecords current? V. B. Fire^n’s Service Elevator_Test Records current? V. C. KeysJ^pt at Fire Command Station?
Yes 0 I^D Yes □ No □ N/A □
V. D. Fire Safety Plan and building floor
Yes<J No □ N/A □
V. E. A current li«r of all floor Wardens and phone v. F. Master wini keys available?
3
plan ^/Fire Command Station? numberp^t Fire Command Station?
Yes 0 No □ YesJ3^ No □ 7 Yes No □ N/A □
V. G. Building current in actual Fire Drills?
(*if over 3 months) WQ No □ 7
___________________ _________________________________________________________________________________ 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 Iryspection—Signs and Charts—
V. A. Are sjatfways properly lettered? V. B. Ate ■properly numbered? V. C. Is flpof diagramposted?
Yes^ /fib □ Y^:
No □ No □
V. D. Are stgfrways re-entry V. E. Are>efevafors properly lettered on each V. F. Is floor dial properly oriented?
siqr^poste^ >etgvator bank?
Yes 0 No/O N/A □ Yes □ No □ n/aJEI Yes, No □
V. G. Is elev^r sign “In Case of Fire, V. H. Are ejit^oors unlocked, closed and V. I. Fire DriH^Ofganization Charts
Use §Jmrs” posted? unobstructed? poi peTand current?
Yes/J No □ N/A □ No □ □ No □
// TOTAL (9)
III. b. Buildingjrj^pection—Signs and Charts—Choose one floor for the general floor inspection '
FLOpR
V. A. Are s^ways properly lettered? V. B. Are><rSrs properly numbered? V. C. Is fh xltagram posted?
Yes/J Nojj Yes □ No □ Yes' No □
V. D. Are stainydys re-entry V. E. Are ele3yat6rs properly lettered on each V. F. Is floor die irf?properly oriented?
sws odsted? eleyaWiir bank?
Yes □ M/A □
No 7
No No □ N/A □ /esU No □
V. G.'Hs elevator sigh “In Case of Fire, V. H. Are exit doprsTIhlocked, closed and V. I. Fire Drill Organization Charts
Use Staird^’ posted? unobstrpcfed? posted andiuwent?
Yes 77 No □ N/A □ Ygs-a No □ Yes77-^0 □
_______ ___________________________________________ _____________________________ ____________________ TOTAL (9) 2
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: ,
LV
NAME OF FLOOR WARI CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor W*Fden have knowledge
A. Positip^urino fire drill or emergency? B. Notificatron procedures? C. Location larm boxes?
Yesd yeU
D. Evacuatjeifi location?
>!es‘n
E. Evacuatifiri procedures?
No □
F. Number. f^xits on floor?
Yes-77' 1 □ . N/A □
G. Exarpiftthg for exits on floor?
3
Yes-0 No-D Y»<3J No Yes O No □____ Yes □ No □_______
H. Reportipq' whether smoke or Fire? I. Dutiesof-OepuW Fire Warden Searchers? V. J. Were fiie-^riUs conducted?
Ye>7j No □ YeU3 No □
*K. Floor wardens in numerous floors properly trained? Yes No □ /
TOTAL (11)
Section B; (II, III, IV) 8 or more answered “NO” in Section B fails. SECTION B TOTAL (36) 7 7
Number of correct answers in this section is Number of incorrect answers is Number of N/A answers is
V25-M 16-870250-3-R25-P
NYC-WTC_000168827
OCR can misread numbers and units. Confirm readings against the page image before using them.