NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes qiPhis 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
Z 01 Inspector
Name of Candidate. A / d Qfjjgg
Office Address
Address. ~ 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 YES NO N/A
further information.
I. Physical Requirements—Does candidate have ability to:
*A. Speak and understand English? * B. Hear spokepTwords over a telephone? *C. Possess nepessary vision?
(with cop^ive devices) (correctiydoevices acceptable)
Yes No n Yes a No □ Yes 0^ 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: x
V. A. Fire driU<ecords current? V. B. Firemi Service Elevator Test Records current? v. C. Keys kej dfFire Command Station?
Yes Cl No □ Yes C No □ N/A □ Yes No □ N/A □
V. D. Fire Safet^lan and building floor V. E. A current list of all floor Wardens and phone v. F. Master window keys available?
J
plan strife Command Station? number^ at Fire Command Station?
Yes No □ Yes 0 No □ Yes No □ N/A
V. G. Building current in actual Fire Drills? {* if over 3 months) Yes 0^ NoQ
_____________________________________________________________________________________________________ TOTAL (7) <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:
Special Instructions—Choose one floor for the general floor inspection
FLOOR
Building Inspection—Signs and Charts—
V. A. Are stairways properly lettered? V. B. Are floys properly numbered? V. C. Is floor diagramposted?
Yes Q No □ Yes a No □ Yes □'^0 □ J
V. D. Are stajrways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
signywsted?
Yes IZ No O N/A □
elevatofztaank?
Yes 0 No □ N/A □ Yes No □ 5
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 □
unobstructed?
Yes nx-^o □
postedand current?
Yes □ No EH J
TOTAL (9) 5
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
FLOOR
V. A. Are stairways properly lettered? V. B. Are floors properly numbered? V. C. Is floo^agram posted?
Yes □ No Q Yes No □ Yes □ No □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor dii igram properly oriented?
sion^osted?
Yes E? No □ N/A □
elevatorbank?
Yes Z" NoO 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 Staifs” posted? unobstructed? posteckdnd current?
Yes □ No □ N/A □ Yes 0 No □ Yes □ No □ -X
________________________________________________________________________________ ___________ ________ TOTAL (9) I
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:^ ,
/u 1^,2 -
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position^urinq fire drill or emergency? I B. Notific^ieff procedures? C. Locatiop^ alarm boxes?
Yes No □
D. Evacuahpriiocation?
I , Yes Cj
E. Evacu^kJn procedures?
No □
F. Nurnbeixd'ff exits on floor?
Yes □
G. Examil
No □ N/A □_____
'for exits on floor?
1
Yes !X Ho □ Yes □ No □ Yes Cj INo □ Yes Z No □
H. Reportina'whether smoke or Fire? I. DutiesoMJepuW Fire Warden and Searchers?
Yes No □ Yes 0^ No □ /
V. J. Were firedrills conducted?
Yes No □ J
* K. Floor wardens in numerous floors properly trained? Yes 0^ No EH f
Section B: (II, III, IV) 8 or more answered “NO" in Section B fails.
TOTAL (11)
SECTION B TOTAL (36)
7Z
Number of correct answers in this section is Number of incorrect answers is . Number of N/A answers is
M25-M 16-870250-3-R25-P
NYC-WTC_000168935
OCR can misread numbers and units. Confirm readings against the page image before using them.