NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes is form must have an answer. Answers 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
J Z 7 _ Inspector
Name of Candidi
(Print last name, first name)
Office Address 7
j
'_______
_
Date of Examination Z-
/Oft yZ
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terminate the test immediately. See Section VIII for YES NO NZA
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?
Yes®^ NoD (with corrective devices) (corrective devices acceptable)
Yes No □ Yes No □
I; 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 dril/rrecords current?! v. B. nremep^Service Elevator_Tost Records current?! v. C. Keyskpffi at Fire Command Station?
Yes^ No □ Yes W No □ n/aD Yes □ No □ N/A □
V. D. Fire Safety plan and building floor V. E. A current li^ of all floor Wardens and phone v. F. Master window keys available?
J
plan Command Station? numberp-af Rre Command Station?
Yes-Q No □ Yes No □ Yes □ No □ N/A
v. G. Building current in actual Fire Drills? 3 months) Yes No □
_________________________________________________________________________________________ TOTAL (7)
Instructions to Inspector—If any violation (V) Hems 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_______ g;________ .
Building Inspection—Signs and Charts—FLOOR
V. A. Are stairways properly lettered? V. B. Are^h^ofs progriy numbered? V. C. Is floor diagram
Yes O' No □
V. O. Are s^rways re-entry V. E. Are elevators properly lettered on each V. F. Is floor
No U
properly oriented?
3
Yes
posted
No □ n/aD
elevatgpbank?
Yes>H No □ n/aC Yes No □ 3
V. G. Is elevator sign "In Case of Fire, V. H. Are exit unlocked, closed and V. I. Fire Drill Oraanization Charts
Use StairsJ’posted? postedandcurrent? 3
Yes 0'^ No □ N/A □ No □ 'j No □
7^ TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection 7
FLOOR
V. B. Are floocs'frroperly numbered? V. C. Is floor
V. A. Are stairways properly lettered?
Yes-gj No □ Yes a No □ 5
V. D. Are stairways re-entry V. E. Are elevmprs properly lettered on each V. F. Is floor dll sgram properly oriented?
n/aD
V. G. Is elevator sign “In Case of Rre.
Ye§/gjNo □ n/aO Yes'l No □
v. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
3
Use St^-posfed?
Yes No □ N/A □
unobstructed?
YesJ3-^o □
posfedand current?
Yes or No □ J
_________________________________________________________________________________________ TOTAL (9)
9
IV. Instructions to Inspector—If four (4) or more items below are marked “NO”, the inspector must issue a Violation Older at
the end of the test. Test must proceed. T
This next part must proceed with contacting a Roor 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
^te'lSiien by you,” , /
FLOOR WARDENS:
NAME OF FLOOR WARDEN CONTACTED FLQ6R CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. PositiorLduringfire drill or emergency? B. Notification procedures? C. Location alarm boxes?
Yesygr NoU
D. Evacuation location? E. Evacu^n procedures? F. Numberbf exits on floor?
Yes0^ No □ N/A □
G. Examining for exits on floor?
3
YosrO No O VbFO No.n Yep^Q No Q Ye^.0^ No □
H. Reporting whether smoke or Fire? I. Duties^! Deputy Fire Warden and Searchers? v. J. Werefife'drills conducted?
Yes a No □ Ye^ No □ Yea-ET No □ 5
*K. Floor wardens in numerous floors properly trained? Ygs-gJ No LJ ~7~
8 or answered “NO” in Section B fails.
TOTAL (11)
SECTION B TOTAL (36)
zz
Section B: (II, III, IV)
Number of correct answers in this section is $___ Number of incorrect answers is Number of N/A answers is Z
M25-14 1&e7(»50-3-R25-P
NYC-WTC_000168862
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