NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes onj|k form must have an answer. Answers witl^^“NO” answers to a “V” mandate a
Violation OrdSiF' NO” answers to a mandate automaSRailure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Z otCfliziAX___________ In.pprtnr £'■ LA\fCLLtr
Name of Candidate__R^L^_^Jj!(L^J^31L13A.£n_£ Office Address Y 1^1- P Date of Examination ___
(Print las. name, firs, name, S'
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terminate the test immediately. See Section VIII for YES NO N/A
further information.
1. Physical Requirements—Does candidate have ability to:__________________________ _________________________
*A. Speak and understand English? * B. Hear spoken words over a telephone? *C. Possess necessary vision?
(with elective devices) (corrective devices acceptable)
Yes [jX No □ Yes [fl No □ Yes No D
: 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 d^ records current? V. B. Firei!men>Servic«lervice Elevator Test Records current? v. C. Keys kepLat Fire Command Station?
Yes [fl No □ Yes [fl No □ ._ □ N/A □ Yes
[B^hio □
N/A □ 3
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 atRre Command Station? numbefaTat Fire Command Station?
Yes [fl No □ Yes [fl No □ Yes □ No □ N/A
V. G. Building current in actual Fire Drills? (*if over 3 months) ^fes^TNoD
_____________________________________________________________________________________________________ TOTAL (7) 6 /
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
/2_
Building Inspection—Signs and Charts—
V. A. Are stajfways properly lettered? V. B. Are floojs-properly numbered? V. C. Is floor diagramposted?
Yes [fl No □ Yes EiX No □ Yes □ No
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
sms posted? elevator bank? f
Yes □ No □ N/A Yes □ No O' N/A Yes □ 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 Stairs" posted? unobstructed? postedaad current?
Yes □ No
I [p N/A □ Yes 3? No □ Yes [fl No □ J /
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
TOTAL (9)
X
FLOOR
V. A. Are sta^ays properly lettered? V. B. Are floors properly numbered? V. C. Is floor diagram posted?
Yes [fl No □ Yes No □ Yes □ No z
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
sms posted? elevatorjjank?
Yes □ No □ N/A B Yes fl No □ N/A □ Yes □ 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 Stairs” post!
iste^ unobstrupted? posted and current?
Yes □ No 0^ N/A □ Yes Ej No □ Yes No □ 1
_____________________________________________________________________________________________________ TOTAL (9) r /
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 WARDES:
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Positiorxauring fire drill or emergency? B. Notificajjon procedures? C. Locatioruof alarm boxes?
Yes 0 No □ Yes [fl No □ Yes No Q N/A □ J
D. Evacuafibn location? E. Evacuatjgfi procedures? F. Number exits on floor? G. Exarninipg for exits on floor?
Yes [fl No □ Yes [fl No □ Yes Er No □ Yes No □
H. Reporting whether smoke or Fire? I. Dutiesof Depu^ Fire Warden and Searchers? V. J. Werefirp drills conducted?
Yes [fl No □ Yes IW No [J Yes [a No □ 3
*K. Floor wardens in numerous floors properly trained? Yes [O No D
TOTAL (11)
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 Number of incorrect answers is . Number of N/A answers is
M25-14 16-e70250-3-R25-P
NYC-WTC_000168966
OCR can misread numbers and units. Confirm readings against the page image before using them.