NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxes^B this form must have an answer. Answei
/ 'W
a “NO” answers to a “V” mandafo^^'s
Violation ler, “NO” answers to a mandate ai : failure. Check “YES” "NO” or “N/A”/W
ON SITE EXAM FOR
FIRE SAFETY DIRECTORY-OFFICE
Z 01 f7 Inspartnr
lame of Candidate. Office Address. Ayr. of Examination
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 spoken words over a telephone? *C. Possess necessary vision?
(withlOTijective devices) (corrective devices acceptable)
Yes No □ Yes.0^ NoD YesS^ 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 drijkf€cords current?! v. B- Firemei irvice Elevator Tost Records current? v. C. Keys
menif^rvicr at Fire Command Station?
Yes ^ No □ Yes n
Nofi N/A □ Yes No □ N/A □
V. D. Fire Safet^lan and building flooi V. E. A current list of all floor Wardens and phone V. F. Master window keys available?
3
plan {Mpife Command Station? nur at Fire Command Station? /
Yes 0 No □ Yes No □ ___ -------------- Yes □ No □ N/A
V. G. Building current in actual Fire Drills? /*jf 3 months) Yes X 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 7
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 stetfways properly lettered? V. B. Are Uoafs properly numbered? V. C. Is flrfo^agramposted?
Yes 0 No □
V. D. Are lairways re-entry V. E. Are elev^rs
Yes 0 No □
properly lettered on each V. F. Is floor
Yes fl No □
diagram properly oriented?
3:
Poste^ elevatoi^nk?
Yes fl No □ N/A □ Yes lx Ni No □ N/A □ Yes No □
V. G. Is elevator sign "In Case of Fire, V. H. Are exit unlocked, closed and V. I. Fire Drill Organization Charts
unob^
X.o’
Use '■ posted? postedjand current?
Yes NoD N/A □ Yes El □ Yes H No □
J a TOTAL (9)
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
Fl•fgsiiR
V. A. Are stairways properly lettered? V. B. Are tioofs^properly numbered? V. C. Is floonsKagram posted?
Yes gf No □
V. D. Are stairways re-entry
Yesg^ No D
V. E. Are elevators properly lettered on each
Yes 0 No □_______
V. F. Is floor diagram properly oriented?
7
signsposted? elevatoGbink?
Yes l/l NoC N/A □ Yes No □ n/aD No □
V. G. is e sign "In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use ' posted? unobsWicted? postedarfd current?
Yes No □ N/A □ Yesfl No □ YesJa 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
be taken by you.”
FLOOR WARDENS:
NAME-OF FLOOR WARDEN CONTACTED / FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
B. Notitificatien procedures?
A. Positioryfluring fire drill or emergency? C. Location of alarm boxes?
Yes X No □ Yes, No □ Yesj2' No □ N/A □
D. Evacuation location? E. Evaci jatjprfprocedures? F. Number^ef exits on floor? G. Exarninjpg for exits on floor?
Yes XI No □ Yes J No □ Yes 0^ No □ Yes.0^ No □_____ _
H. Reportii whether smoke or Fire? I. DutiesofHDepu^ Fire Warden and Searchers? V. J. Werefipe drills conducted?
Yes 0 No □ YesJZr No □ YesJ^ No □
*K. Floor wardens in numerous floors properly trained? Yes 0" No Q
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
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