NYC 9/11 Public Portal Document
Instructions to Inspectors—All box^^n this form must have an answer. Answe^^ith a “NO” answers to a “V” maht.^
Violation Order, “NO” answers to a mandate automatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
Name of Candidate.^Hl^iffiCQj^L_J|0i^P8S® Office Address _ Date of Examination
(Print lasTnamZfirst 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 ^derstand English? *B. Hear spoken words over a telephone? *C. Possess n^essary vision?
(with inive devices) (corrective devices acceptable)
Yes No □ Yes E No □ Yes Hr 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 drill records current? V. B, Firemen’s Service Elevator Test Records current? v. C. Keys kept at Fire Command Station?
Yes □ No □ Yes □
Yes □ No □ N/A □
N/A □ Yes □
Yes □ No □
No □ N/A □
N/A □
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? numbers at Fire Command Station?
Yes □ No □ Yes □ No □ Yes □ No □ N/A □
V. G. Building current in actual Fire Drills?
(*if over 3 months) Yes □ 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.
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for the general floor inspection
FLOOR
Building Inspection—Signs and Charts—
V. A. Are sWirways properly lettered? V. B. Are floefrs properly numbered? V. C. Is floor^gramposted?
Yes ZJ No □
V. D. Are stairways re-entry V. E. Are el
Yes 0 No □
properly lettered on each
Yes 0 No U
V. F. Is floor diagram properly oriented?
J
sioBs posted? elevati ink?
Yes /-I No O N/A □ Yes No □ N/A □ Yes No □
V. G. Is elilev^r sign “In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use! Stairs" posted?
Yes B No □ N/A □
unobi
Yes t
ed?
No □
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
posted^d current?
Yes0 NoO
7
/ 4^
FLOOR
TOTAL (9) 4
V. A. Are stairways properly lettered? V. B. Are floors properly numbered? V. C. Is flqo|^iagra ?
Yes No □ Yes E No □ ' Yes ffl No
V. D. Are stairways re-entry V. E. Are elevi properly lettered on each V. F. Is floor diagram properly oriented?
elevatqai ink?
sign^ posted?
Yes 1^ NoO N/aO
V. G. Is elevatpf sign “In Case of Fire,
Yes Cf No □ N/A □
V. H. Are exi^oors unlocked, closed and
Yes/J No □
V. I. Fire Drill^rganization Charts
3
Use Staffs” posted? unobstAicted? posted^d current?
Yes QD No □ N/A □ Yes B No □ Yes IZ 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
//
NAmFoF FLOOR WARDEN CONTACTED FLOOR Chosen TELEPHONE NUMBER
Does Floor Varden have knowledge of: X
A. Positiory^uring fire drill or emergency? B. Notifjorfion procedures? C. Locati9<(of alarm boxes?
Yes [Z No □ Yes E No □ ,______ Yes IZ No N/A □
D. Evacuatjdfi location? E. Evacua^n procedures? F. NumbX'of exits on floor? G. Exarni^g for exits on floor?
Yes 0^ No □ Yes [/ Ng/O Yes IZ No □ Yes 0 No □
H. Reporting'^hether smoke or Fire? I. Dutie^f DepuW Fire Warden and Searchers? V. J. WerefjXdrills conducted?
Yes No □ Yes 0 No □ Yes 0 No □
*K. Floor wardens in numerous floors properly trained? Yes X Ho □ TOTAL {l1)
/
Section B: (II, III, IV) 8 or “NO” in Section B falls. 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_000168776
OCR can misread numbers and units. Confirm readings against the page image before using them.