NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes o^Ris form must have an answer. Answers I “NO” answers to a “V” mandate a
Violation Oraer, “NO” answers to a “*” mandate automj failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Inspector
Name of Candidate Office Address, Date of Examination
^(Print last 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 Requl/dBiehts—Does candidate have ability to: ---- ------ ----------------------------------------------------
*A. Speak an^nderstand English? *B. Hear spokei Is over a telephone? *C. Possess BcasSary vision?
3
(with coiTpdive devices) (corr^ 'oevices acceptable)
Yes [2^ No 0 Yes No □ Yes*kf No □
I: Building
Instructions to li r—If any violation (V) items are marked “NO”, issue a Violation Older at the end of the Test. Test must
proceed.
II. Records: ,
V. A. Fire d^ records current? V. B. Firemen’s Service Elevator Test Records current? v. C. Keys
s kegt^t Fire Command Station?
Yes 7 N^ □ Yes □ No □ N/A □ Yes CZ No □ N/A □
V. D. Fire Safe Plan and building floor V. E. A current st of all floor Wardens and phone v. F. Master window keys available?
er ire Command Station?
No □
V. G. Building current in actual Fire Drills?
number?^ Fire Command Station?
YesO^ No □
/*jf 3 months) Yes □ No □
Yes □ No □ N/A
____________________________________________________________________________________________________ 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 li)spectlon—Signs and Charts—
V. A. Are^gHfways giperly lettered? V. B. Are flogrZproperly numbered? V. C. Is flogt-dtiigramposted?
vTaAre^iffwa^re-entry
Yes a No □
V. E. Are el svatgrsr^perly lettered on each V. F. Is floor
Yes □ No □
properly oriented?
3
sign?r posted?
Yes □ No □ N/A □
elevati
Yes IZ
ink?
No □ N/A □ Yes No □ 3
V. H. Are exit doprt unlocked, closed and V. I. Fire Drill Organization Charts
V. G. Is elevatop^gn “In Case of Fire,
Use St^s” posted?
YesZl No □ N/A □
unob^rudfed?
Yes-0 No □
postedancT current?
Y0S~O No □
3
TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection ZCT 7^
FLOOR
V. A. Are staijwSys properly lettered? V. B. Are fl iFoperly numbered? V. C. Is floor diagram posted?
Yes 0 No □ Yes-E YesO: No □
V. 0. Are kWays re-entry vTETAreeievatow^pro^irly lettered on each V. F. Is floor dji igfam properly oriented?
sign osted? elevato^Jsdnk?
Yes/0 No □ N/A □ Yes-0^ 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 StakgP^sted? unobstructed? posted and current?
YesXS' No □ N/A □ Yes nZNo □ YesJ3-^o □
______________________________________________ 2_______________________________ ____________________ 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-i'ln the event of a fire on this floor, explain which specific actions must
NAME OF FLOOR WARDEN C0^3<CTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor i^rden have knowledge of:
A. Positiop»*fiurinQ fire drill or emergency? B. Notificatiefi procedures? C. LocatioB-dfalarm boxes?
YesH >ioD ^es □ No □ Yes No □ N/A □
2
D. Evacuaji^tn location? E. Evacu^itidfi procedures? F. Numb^of exits on floor? G. Examinino-foTexits on floor?
Yes'C No □ Yes 0^No □
YesiX No □ Yes lZ No □
H. ReporUijg “whether smoke or Fire? I. DutiesqfzB^puN Fire Warden and Searchers? V. J. dnllsconducted?
YesM No □ Yes^B"^ No □ ' No □
*K. Floor wardens in numerous floors properly trained? YesJ3—'noTJ
TOTAL (11) 77
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
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