NYC 9/11 Public Portal Document
Instructions to Inspectors—flrooxe^^ this form must have an answer. ^HUwr^^h 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—OFOCE
J Z 01 inspect,
p)?Py2^kf Office Address P
Name of Candidate. of Examinat
(Print last nam^fifsTname) ’ J\/* ‘ 1^* '
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 and understand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision?
Ye^ No D___________ (witi^rrective devices) (correctjye devices acceptable)
Yes/Ok No D Yes^ No[D
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^ records current? V. B. Fireman'I's Service Elevator Test Records current? v. C. Keys. at Fire Command Station?
Yes □ No □ YesSZL No □ N/A □ Yes No O N/A □
V. D. Fire fit tety Plan and building flooi %. E. A current list of all floor Wardens and phone v. i^Master window keys available? (
plan^ Fire Command Station? / numbers at Fire Command Station?
..jmbers .
Yes E No □ No □
V. G. Buildin current in actual Fire Drills? (*if over 3 months) Yes^' NoD
Yes □ No □ N/A^
X
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.
I
Hi. a. SpecHic Buildiing Inspection:
Special Instructions—Choose one floor for the general floor inspection.
FLOOR'
Building Inspection—Signs and Charts—
V. A. Are^arways properly lettered? V. a Are floors properly numbered? V. C. Is floor diagram I?
Yesi^ NoU Yes-SJ No D Yes Q No □
V. D. Are siairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
r-,
elevator bank?
Yes^ No D N/A D Yes □ No N/A D Yes □ No&
V. G. Is sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Dril/Organization Charte
Use Stairs’* posted? unobstructed? posted and current?
4
Yes D No'S N/A D YeS'^ No D Yes^ No D
TOTAL (9)
III. bl Building Inspection—Signa and Charts—Choose one floor for the general floor inspection rx~
FLOOR
V. A. Are irways properly lettered? V. a Are floors properly numbered? V. C. Is floor diagram posted?
Ybs ' No □ Yes KI No D _______ Yesyi No D______ >
V. D. Are lirways re-entry
posted?
Yes LA NoD N/A □
V. E. Are elevatorsimproperly lettered on each
elevator bank*
Yes IS. No □ N/A □
V. F. Is floor diagram properly oriented?
Yesl^ NoD
r
V. G. Is^lilevator sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I( Fire Drill Organization Charts
Use,^irs” posted? unobaructed? post^and current?
Ybs TS No D n/aC Yes IX No □ Yes No D 2^
IV. Instructions to Inspector—If four (4) or more Hems below are marked “NO”, the inspector must issue a Violation Order at
the end of the test. Test must proceed.
TOTAL (9)
4-
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 spaciflc actions must
FLOOR WARDENS:
NAME OF FCSOR vArOEN CONWCTED
Does Roor Warden have knowledge of:
A. Pos luringflre drill or emergency? a Notification procedures?
| -4^ TELEF>HONE NUMBER
C. Locajon of alarm boxes?
Yes NoD Yes'SZl No D YteIX NoD n/aD
tion location? E. Evaiju^on procedures? F. Numtaf of exits on floor? G. Examining for exits on floor?
No □ Yes/S No D Yes A NoD Ye^ No D_______
H. Reporting whether smoke or Fire? I. Dutiespf Deputy Fire Warden and Searchers? V. J. Were fire drills conducted?
Yes C No □ Yes SI No D YesJ0 No D_________
*K. Floor wardens in numerous floors property trained? ■^sD No D
TOTAL (11)
Section B: (II. HI. IV) 8 or “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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NYC-WTC_000168857
OCR can misread numbers and units. Confirm readings against the page image before using them.