NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxe^^ this form must have an answer. Answe^^ith 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
'lame of Candidate. Office Address. 3. ■ 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-Poes candidate have ability to:
*A. Speak and understand English? *B. Hear spoken words over a telephone? *C. Possess necessary vision?
(with corrective devices) (corrective devices acceptable)
Yes.ZC No □ Yesza NoD - 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. RecortiA:
V. A. Fire drilStqcords current? V. B. Firemen’s Service El F ei [s current?! v. C. Keys kept at Fire
FireCorrifnand Station?
Yes □ N&<1 Yes □ No □ N/A Yes □ N I jmB''^ N/A □ 3
V. D. Fire Safety Plan arid-building floor V. E. A current list ill and phone V. F. window keys available?
plan at Fire CommandStatjon?
Yes □ No □
numbers at Fii
Yes □ No Yes □ No □ N/A □
3
V. G. Building current in actual Fire Drills?\z*jf 3 months) YesC
-t
TOTAL (7)
Instructions to Inspector—If any violation (V) items ai irked issue a Violation Order at the end of the Test. Test must
Proceed.
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for leneral floor in!
Building Inspection—Signs and Chayts^ FLOOR
V. A. Are stairways goperly
-Yes □ No
V. B. Are floors
Yes □ M
pi pperw r umttZ
V. E. Are elevators properly let erb^rJeach
fSd? V. C. Is floor diagram
^^\Yes Q No C
I?
s
V. D. Are stairways V. F. Is floor'diagjam properly oriented?
signs posted^,
Yes □ Np® N/A □
elevator bank?
Yes □ No □
N/A □
\
Yes □ No □
3
V. G. Is tor sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organizati
Use Stairs” posted? unobstructed? posted and current? 3
Yes □ No □ N/A □ Yes □ No □ Yes □ No □
TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection ^5.
FLOOR
V. A. Are stairways properly lettered? V. B. Are floors properly numbered? V. C. Is floor diagram posted?
Yes^ No □ Yes^ No □ YesrC No □ 3
v. D. Are stainways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
sigrw posted? elevator bank?
Yesz0^ No □ N/A □ Yes-0^ No □ N/A □ YeszEf 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 Steps” posted?
YesJ2^ No □ N/A □
unobstructed?
YesJ^ NoO
post^ and current?
Yes^ No □ 3
_____________________________ ___________________________________________________ ____________________ TOTAL (9) 7
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—i* In the event of a fire on this floor, explain which specific actions must
FLOOR WARDENS: be taken t^ou.
____________ ( rrfe z I IT-
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Ftosig>dorin^re drill or emergency? B. Notifica^ procedures? C. Location alarm boxes?
Yes-0''"^ No □ Yes,^ No □ N/A □ 3
D. Evacuatior). location? E. Evacuation procedures? F. Numbej^of exits on floor? G. Exarnining for exits on floor?
Yes..S^ Mo □ Yes.0^ No □ Yes/ET No □ YesxB^^ No □_________ __
H. Reportipg whether smoke or Fire? I. Duties of Oepiig Fire Warden and Searchers? V. J. Wecefire-drills conducted?
YeSzZl No □ ~ Yes^B'^No Yes No □ 3
*K. Floor wardens in numerous floors properly trained? Yes.BT No □ L
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
NYC-WTC_000168754
OCR can misread numbers and units. Confirm readings against the page image before using them.