NYC 9/11 Public Portal Document
Instructions to Inspectors—All box^ this form must have an answer. Answi ith a “NO” answers to a “V” mandate a
Violation irder, “NO” answers to a mandate automatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAF^Y DIRECTOR—OFFICE
z 01 ________ Inspector
Name of Candidate, a , J-. Office Address. Date of Examination 7 - Z/
(Print last name, first hame)
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 Requiremgpts—Does candidate have ability to:
*A. Speak and ufitJerstand English? * B. Hear spoken over a telephone? * C. Possess necess^ vision?
(with cor^eefive devices) (corrective^JeviCes acceptable)
Yesz0^ No □ Yes Q^^o □
Yei No □
: 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:
irvice Elevator Test Records current? v. C. KeysJ^ at Fire Command Station?
V. A. Fire ddH<ecords current? V. B. Firemen^
Ye<n No □
V. D. Fire Safety Plan and building floor
Yes-0^ No □ N/A □ Yes No □ N/A □
V. E. A current list of all floor Wardens and phone V. F. Master window keys available? .
J
plan atfir^Command Station? numbejs^aTFire Command Station?
Yes 0'^ No □ Yes 0 No □ Yes □ No □ N/>
V. G. Building current in actual Fire Drills? (*if over 3 months) Yes □ No □
__________________ __ _______________________________________________________________________________ TOTAL]^ cr
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 stair>«ys properly lettered? V. B. Are fjogts-properly numbered? V. C. Is floor diacitamposted?
Yes-Q No □ Yes □ !
Yes No □
V. D. Are stairways re-entry V. E. Are elevatqrg properly lettered on each V. F. Is floor diagram properly oriented?
elev^QpbSnk?
signs,^9(5sted?
Yes a No □ N/A □
V. G. Is elevator sign “In Case of Fire,
Yes'S No □ N/A □
V. H. Are exit doors unlocked, closed and
Yes, No
V. I. Fire Drill Organization Charts
3
Use Si
Yes E
■^posted?
No □ N/A □
unobstructed?
Yes0r No □
posted anjLeorrent?
Yes.^'^No □ 3
Z TOTAL (9) /}
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
FLOgfR
V. A. Are stairways'properly lettered? V. B. Are floors properly numbered? V. C. Is floor diagf^m posted?
Yes B^No □ Yes. No Yes □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagr^ properly oriented?
signsjxisted? elevator bank?'
YesS''^ No □ N/A □ Yes <^o □ N/A □ Yes No □ 3
V. G. Is elevator sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Stairs” posted? unobsjropted? posted and cywertf^ 7
Yes EX-'d'IoU N/A □ Yes-a No □ Yes O
________ ______________________________________________________________________ ____________________ 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 actions must
be taken by you.”
FLOOR WARDENS:
NAME OF FLOOR WARDEN CONTACTED /telephone/number
Does Floor Warden have knowledge of:
A. Positioj>-dLirinQ fire drill or emergency? B. Notification procedures? C. Location of alarm boxes?
YesdO >Jo U Yes □ No □ Yes □ No □ N/A □ 3
D. EvacuSl^ location? E. Evacuation procedures? F. Number of exits on floor? G. Examining for exits on floor?
Yes □ .No n Yes □ No □ Yes □ No □ Yes □ No □
H. Repojt^ whether smoke or Fire? I. Duties of DepuN Fire Warden and Searchers? V. J. Were fire drills conducted?
Yes □ No U Yes □ No □
*K. Floor wardens in numerous floors properly trained? Yes □ No □
TOTAL (11)
Section B: (II, III, IV) 8 or more anpwcTed “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 7
M25-14 16-07O25O-3-R25-P
NYC-WTC_000168903
OCR can misread numbers and units. Confirm readings against the page image before using them.