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
1
Violation irder, “NO” answers to a mandate automatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Z 01 g*"' Inspector
Name of Candidate. Office Address. 7 - <■ Date of Examination
(Print last name, first name)
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terminate the test immediately. See Section VIII for YESjNO N/A
further information.
LPhysicalRequirements—Doescandidatejiaye^bilityjo^
*A. Speak andI upderstand English? * B. Hear spokeppwdrds over a telephone? *C. Possess necegsafy Vision?
(with cQfFdStive devices) (correctiye-devices acceptable)
Ye! No □ YesBT No □ Yes ZT 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.
11. Records:
V. A. Fire dnljx^ords current? V. B. Firemen>-8CTirvice Elevator Test Records current? v. C. Keysjrei a^R^Command Station?
Yes B No □ , Yes-E: No) □ N/A □ Yes No □ N/A □
V. D. Fire Safety PlarTand building floor V. E. A current list oLatt'floor Wardens and phone v. F. Master window keys available?
plan atFireCommand Station? numbei^jrt-Tlre Command Station?
Yes No □ Yes-0'^ No □ Ye: No N/A
V. G. Building current in actual Fire Drills? (*if over 3 months) YWC No □
_____________________________________________________________________________________________________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
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for the general floor inspection
FLOOR
Building Inspection—Signs and Charts—
V. A. Are st^ rays properly lettered? V. B. Are flooj^^pToperly numbered? V. C. Is floor diagram Dosted?
Yesx0
V. D. Are stall
No □
's re-entry
Yes No □
V. E. Are elevator^roperly lettered on each
Yese--^^Nrn
V. F. Is floor diagram properly oriented?
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siqnj-fJcosted? elevatorbarrk?
Yes>< INo □ N/A □ Yes- No □ N/A □ YeHZT^ No □
V. G. Is elevator sign “In Case of Fire, v. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Staii>^osted?
YesJ-Y No □ N/A □
unobstructed?-
Yes □--‘^o □
posted anjLeurrent?
YesJEr No □
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TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
FLOOR
v. A. Are staipivdys properly lettered? V, B. Are floorg-pfoperly numbered? v. C. Is floor diagram posted?
Yes 13^ No □ Yes -0^ No □ Yes f< No □ 3
V. D. Are staipways re-entry V. E. Are elevators properly lettered on each V. F. Is floor dii igram properly oriented?
signs^sted?
YesJCJ No □ N/A □
elevator rhk?
Yes S' No □ N/A □ Yes' No □
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V. G. Is elevatoi ^sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use St^” posted?
Yesy0 No □ N/A □
unobstructed?
Yes No □
postedantj current? 3
Ye>0 No □
________________________________________________________________________________ ____________________ 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:
NAMEOF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Positiomddfinghre drill or emergency? B. Notificatior^procedures? C. Location alarm boxes?
Yes 0'^ JMo □
D. Evacuf^n location?
Yes
E. Evacuation procedures?
Mo □
F. Number of exits on floor?
Yes O' No □ N/A □
G. Examining“for exits on floor?
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Yes □ ^lo □ Yes No □ Yes No □ Yes Cl No □
H. Repor>lg whether smoke or Fire?
Yes □ No □
I. Duties of Deputy Fire Warden and Searchers?
No □
V. J. Were fire drills conducted?
Yes-ET No □ T
* K. Floor wardens in numerous floors properly trained?
Section B: (II, III, IV)
Yes-B"^ No C
8 or more angered “NO” in Section B fails.
TOTAL (11)
SECTION B TOTAL (36)
3
gm
Number of correct answers in this section is
M25-M 16-870250-3-R25-P
Number of incorrect answers is Number of N/A answers is
2
NYC-WTC_000168906
OCR can misread numbers and units. Confirm readings against the page image before using them.