NYC 9/11 Public Portal Document
Instructions to Inspectors—^Loxe^^ this form must have an answer, ^kvetfbith 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 ____ . Inspector
Name of Candidate. X—Ml ohI Office /Address.
(Print last name, first name)
^Examination
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 I understand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision?
(withcorrective devices) (corrective devices acceptable)
Y^V INo □ Yes^ No □ Yes^ NoD
i: Bulldlr^ '
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. Firedrill records current? V. B. Firemen’s Service Elevator Test Records current? v. C.
Yes 0^ No □
V. D. Fire Safety Plan and building floor
<
No □
■ ■
N/A □ ay
at Are Command Station?
No □ N/A □
A current list of all floor Wardens and phonel v. F. (Master window keys aval
plan at Fire Command Station? nur at Fire Command Station?
YesOy No □ Yes No □ Ybs □ No □ N/A
V. G. Building current in actual Fire Drills? (*if ov 3 months) Yes^ No □
f 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.
Building Inspection—Signs and Charts—
V. A. Are.^irways property lettered? V. B. Are.flpors properly numbered? V. C. Is floor diagramposted?
Yas^ No □
Y68® No □ Yes □ No X
V. D. Are/stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
signs posted? elevator bank?__.
Yes K No □ N/A □ Yes □ n NoV
N/A □ Vbs □ No K
V. G. Is ^levator sign “In Case of Are, V. H. Are Iexit doors unlocked, closed and V. I. Are Drill Organization Charts
Use Stairs'-' po^f‘I? unobstructed? posted and current?
NA □ Yes^ No □
YIbs □ Yes □ No □
TOTAL (9) 5
Hi. b. Building Inspection—Signe end Charts—Choose one floor for the general floor inspection
V. A. Are steirways lettered? V. a Are floors properly numbered? V. C. Is flw idiagram
Ybs S No Yes SC NoC YesSI No C
V. D. Are stairways reentry V. E. Are elevators properly lettered on each V. F. Is floor ditigram properly oriented?
fe poste^ elev^r bank?
Yes^ NoD
Yes " No □ N/A □ Yes tX No n N/A □
V. G. sign “In Case of Are, ^v H. Are exit doors unlocked, closed and V. /. Fire Drill Organization Charts
Use SMrs” posted? unob^cted? / posted and current?
• ViBS No □ njaD YesS No □ ' Yes^ No □
________________________________________________________________________________ ____________________ TOTAL (9)
IV. Instructions to Inspector—If four (4) or more items below are nnarked “NO”, the inspector must issue a Violation Order at
the end of the test. Test rnust proceed.
This next part must proceed with contacting a Floor warden within the Building. Read the following
5
statement to the Warder»-i‘ln the event of a fire on this floor, explain which specific actions must
rUUJEOF^OORi^DEN CCJfnACTED
Does Roor Warden have knowled^Jof:
-iU
FWOR CHOSEN TELEPHONE NUMBER
A. Posit duringfire drill or emei B. NotifiMtion procedures? c. Locmfon of alarm boxes?
Tbs'' No □ Yes O No □ Yes^ No □ ___________
n/aQ
D. Eva^ tion location? procedures? F. Number of exits on floor?’ G. Exarnirnng for exits on floor?
Yes No □ No □ Yes S. No □ Yes No □
H. Rep< whether smoke or Fire? L Dm
Dutii^of Depig Fire Warden and Searchers? V. J. Wete^re drills conducted?
Yes No □ Yes Yes® No O X
*K. Floor wardens in numerous floors properly trained? Yes'® No □
TOTAL (11)
K
Section B: (II, III, IV) 8 or more answered “NO" in Section B falls. SECTION B TOTAL (36)
Number of correct answers in this section is 7j , Number of incorrect answers is Number of N/A answers is j
M2S-14 1&«702SO-3JOS-P
NYC-WTC_000168855
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