NYC 9/11 Public Portal Document
Instructions to Inspectors—All boxe^B this form must have an answer. Answe a “NO” answers to a “V” mandate'
Violation Oraer, “NO” answers to a mandate automatic failure. Check “YES” “NO” or “N/A”.
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
2 01 Inspector
ame of Canriirinte
(Print las, name, firs, name)
Office Address 7 of Examination 4—
Instructions to Inspectors—If any asterisk (*) items are marked “NO”, terminate the test Immediately. See Section VIII for YES NO WA
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?
(with corrective devices) (corrective devices acceptable)
Yes □ No □ Yes □ No □ YesO Non
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? I v. B. Fireimenjs^ervicr /s
irvice Elevator Test Records current? v. C. Keys at Fire Command Station?
Yes 0 No □ Yes
[^noD n aq n / Yes• No □ 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?
3
plan at Fire Command Station? numbers-at Fire Command Station?
Yes 0^ No Q Yes 0^ No □ x- Yes □ No □ N//V0*^ c
V. G. Building current in actual Fire Drills?
(*if over 3 months) YesM NoD
_________________________________________________________________________ ___________________________ 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
I
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 stajpitfays properly lettered? V. B. Are ffoofs^roperly numbered? V. C. IsfloordiagrarTiposted?
Yes M No □ Yes 0*^ No □ Yes No □
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
siahAlSosted? elevate bank?
Yes-0^0 □
Yes Id No □ N/A □ Yes No □ N/A □
V. G. Is elevator sign "In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Staix8**'posted? unobstruot^? postedJrfid current?
Yes 0 No □ N/A □ Yes No □ Yes 0 No □
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
TOTAL (9) 2
V. A. Are ays properly lettered? V. B. Are ffoope-properly numbered? V. C. Is floor diagram posted?
Yes No □__________ _
V. D. Are stairways re-entry
Yes0 NoD________ ___
V. E. Are elevatois properly lettered on each
Yes 0^ No □_______
V. F. Is floor diagram properly oriented?
3
sioQs^sted?
Yes 0 No □ N/A □
V. G. Is elevator sign "In Case of Fire,
elevator^ank?
Yes A No □ N/A □
V. H. Are exit dpors unlocked, closed and
Yes No □
V. I. Fire Drill Organization Charts
3
4
Use posted? unob^nidted? postedafxfcurrent?
Yes 0^ No □ N/A □ Yes 0 No □ Yesjd 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 WMibEN CONTACTED FLOOR fcHbSEN TELEPHONE NUMBER
Does Floor Warden have knowledge"^of: ________________________
A. Positionyftirinq Are drill or emergency? I B. Notificatjen procedures? C. Location alarm boxes?
Yes Id No □ I Yes 0 No □ YesS"^ No □ N/A □
D. Evacuatipd location? E. Evacuatfop^rocedures? F. Numbei^exits on floor? G. Exam^g for exits on floor?
Yes 0^ No □ Yes Cd No □ Yes No □ Yes 0 No □________
H. Reporting^whether smoke or Fire? I. Dufies ofJJepuN Fire Warden and Searchers? V. J. Werefiro drills conducted?
Yes No □ Yes No □ Yes No □ 3
*K. Floor wardens in numerous floors properly trained?
Section B: (II, III, IV)
Yes 0*" No □
8 or more answered “NO” in Section B fails.
Number of correct answers in this section is . Number of incorrect answers is
TOTAL (11)
SECTION B TOTAL (36) 2
Number of N/A answers is
«25-M 16fl70250.3fl254>
NYC-WTC_000168792
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