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 SAF^Y DIRECTOR—OFFICE
Z 01 4 / __________ Inspector
Name of Candidate 3 ^-1 < Office Address A/ - *7"' CS- Date of Examination
(Print last name, first name) yf
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 anp understand English? * B. Hear spoken words over a telephone? * C. Possess nepessary vision?
(with corrective devices) (corrertiye^evices acceptable)
Yes iM No □ Yes [S' No D Yes a 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:
V. A. Fire driU/fecords current? V. B. Firemen^ 'Service Elevator^Test Records current?| v. C. Keysjropf'at Fire Comm^ Station?
Yes S' No □ Yes O' No □ N/A □ Yes No □ N/A □ J
V. D. Fire Safety Plan and building floor V. E. A current list of all floor Wardens and phone V. F. Master window keys available^
plan at Fire Command Station?
Yes No □
numbefS^at Fire Command Station?
Yes M No □ Yes □ No □ N/A
£ /
V. G. Building current in actual Fire Drills? (* if over 3 months) Yes No O
_____________________________________________________________________________________________________ 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.
III. a. Specific Building Inspection: j
Special Instructions—Choose one floor for the general floor inspection .
Building Inspection—Signs and Charts—FLOOR
V. A. Are st^ways properly lettered? V. B. Are flpdrs properly numbered? V. C. Is floor, diagramposted?
Yes Db No □ Yes □ No □ Yes 0 No □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
si^ poste^ elevatoizlSank?__ z dS- Yes 0^ No □
Yes E No □ N/A □ Yes 0 No a N/A □
V. G. Is elevator sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use S^s" posted? unobstrpcted? posted and current?
Yes 0 No □ N/A □ Yes IZ No □ Yes □ No 0"
TOTAL (9) 1
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection /'o
FLOOR
V. A. Are stahways properly lettered? V. B. Are floors^roperly numbered? V. C. Is floor>lidgram posted?
Yes No □ Yes No □ No O >
V. D. Are stairways re-entry V. E. Are elevators ^property lettered on each V. F. Is floor dii jgfam properly oriented?
signsposted? elevatoi ink'
Yesz0 No □ N/A □ Yes0 No □ N/A □ Yes No □ 7
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?
Yes No □ N/A □
unobstrujjea?
Yes No □
posted arjd^current?
Yes No □ 7
________________________________________________________________________________ ___________ 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:,^ J , /
/€> ' //YY
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. PositiopzJurina fire drill or emergency? I B. Notific^i^ procedures? C. Locato alarm boxes?
J
z
Yes □ No U I z'Yes U No □ Yes Q No □ N/A □
D. Evacuation location? E. Evacuatidh procedures? F. Number of exits on floor? G. Examinim^^dTexits on floor?
Yes 0 No □ Yes 0 No El Yes □ No □ Yes Ey No □
H. Reporti^whether smoke or Fire? I. DutiesoiZlepu^Fire Warden and Searchers? V. J. Were fir^rills conducted?
Yes No D Yes Er No U Yes No Q
*K. Floor wardens in numerous floors properly trained? Yes No O
TOTAL (11)
X
7Z
Section B: (II, III, IV) 8 or more answered “NO” in Section B fails. SECTION B TOTAL (36)
Number of correct answers in this section is V Number of incorrect answers is XJ Number of N/A answers is
M25-14 16-070250-3-n25-P
NYC-WTC_000168932
OCR can misread numbers and units. Confirm readings against the page image before using them.