NYC 9/11 Public Portal Document
Instructions to Inspectors—All botll^n this form must have an answer. A
■th 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—OFFICI
Z 01 inspector_____
y Office Address.________ 7_____
fame of Candidae. 7 Date of Examination.
(Print last name, first name)
/y/y <l/\/
Instructions to Inspectors—If any asterisk (*) Herns 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 andl^derstand English? *B. Hoar spoken words over a telephone? *C. Possess necessary vision?
(with copecrive devices) (corrective devices acceptable)
Yes k No □ Yes E No □ Yes B^-TIo □
Building
Instructions to Inspector—If any violation (V) items are marked “NO”, issue a Violation Order at the end of the Test. Test must
prooBOd.
II. Records: _____________________________________________________________
V. A. Fire drill fdcords current? V. B, Firemep<S_ Service Elevator Tea Records current? v. C. Keys Fire Command Station?
YesBr Non Ye»0 No □ n N/A □ Yej No □ N/A □ 3
V. D. Fire Safety Plaipand building flooi V. E. A current Ua of all floor Wardens and phone v. F. Maaer window keys available?
plan a Firp-<5ommand Station?
Yes No □
numba»<at Fire Command Staion?
Yes 0 No □ Yes □ No □ N/A-B^ ?
V. G. Building current in actual Fire Drills? (*,( 3 months) Yes-Q NoD /
__________________________ ____________________________________________ _______________ _______________ 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
2 z
Proceed.
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for the general floor inspection
7'
FLOOR
Building Inspection—Signs and Charts—
i V. A. Are aaipwOys properly lettered? V. a ^(^toocs-pfti^rly numbered? V. C. Is floordigoFam I?
Yes^I No □ YbaS'No C
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
signj^pOsted?
Yes ET No □ n/aD
elevator bank?--"
Yes ^-No □ N/A □ rarQ No □ 3
V. G. Is elevator sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Driliprganization Charts
Use Stairs’’^ posted?
Yes S^No □ N/A
unobaroeiefl?
YesS^ No □
poaed'ffiid current?
No □
3
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
V. A. Are stairways properly lettered? V. B. Are floorsjjroperiy numbered?
Yes-0'No □
7^
V. C. Isfloorpiagraro posted?
YIbs-EJ No □
TOTAL (8)
7
Yes <0 □
vToTAreaainOT^'re^entry^ V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
sigr^.poSied? elevator bank?
Yes<a No □ N/A □ Yes-B----- No □ N/A □
V. G. Is elevator sign "In Case of Fire, V. H. Are exit do^ unlocked, closed and V. 1. Fire Drill Organization Charts
unobgwcted?
YeSTJ No □
post^^d current?
YesCJ No □
3
_ ___________ ________ _ _________________________________________________________ _____________________ 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—‘‘In the event of a fire on this floor, explain which specific actioru must
be taken by you.”
FLOOR WARDENS:
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN telephone number
Does Roor Warden have knowledge of:
igfii drill or emergency? B. Notification procedures?
A. Position duringflre C. Location of alarm boxes?
YbsQ Yes □ No □ Yes □ No □ n/aO
NoI □
D. Evacuation location? E. Evacuation procedures? F. Number of exits on floor? G. Examining for exits on floor?
Yes □ No □ ViBS □ No □ Yes □ No □ Yes □ No □
H. Reporting whether smoke or Fire? I. Duties of Depig Fire Warden and Searchers? V. J. Were fire drills conducted?
Yes □ No □ Yes □ Yes □ No □
*K. Floor wardens in numerous floors properly trained? Yes □ No D
TOTAL (11)
Section B: (II, III, IV)_____________ 8 or more answeiired “NO" in Section B fails. SECTION B TOTAL (36) V
Number of correct answers in this section is j . Number of incorrect answers is Number of N/A answers is 7^
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