NYC 9/11 Public Portal Document
A ■ *
Instructions to Inspectors—All boxes on this form must nave an answer. Answers with a “NO” answers to a “V” a
Violation Order, “NO” answers to a “*” mandate automatic failure. Check “YES” “I
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
__ Inspector. { 6a f/V
Ol Z? f IC gxamin,
Name of Candidate. __ Office Address.
(Print last name, first name)
A:
yvy
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?
(with corrective devices) (correchxe devices acceptable)
Yes “5^ No O Yes No □ YesJSl No □
B: BuiWhrg___________________________________ ____________________ 2____________________
Instructions to Inspector—If any violation (V) Hems are marked “NO”, issue a Violation Order at the end of the Test. Test must
proceed.
II. Records: x
V. A. Fire records current? V. B. Firemen^
men s Servict
Service Elevator Test Records current? v. C. Keys topt at
_.Fire Command Station?
Yes No □ Yes 5^ noD
V. D. Fire Safety Plan and building floor
N/A □ Ye^ No □ N/A □
V. E. A current list of all floor Wardens and phone V. F Master window keys available?
5
plan_^^e Command Station? nurnters at Fire Command Station?
Yes'^ No □ Yes M No □ Yes □ No □ N/aXI /
V. G. Building current in actual Fire Drills? 3 months) Ye^S5 No □ I
Instructions to Inspector—If any violation (V) items are marked “NO”, issue a Violation Order at the end of the Test. Test must
Proceed.
TOTAL (7)
s
III. a. Specific Building Inspection:
Special Instructions—Choose one floor for the general floor inspection
Building Inspection—Signs and Charts—
FLOOR
nfl /I/O $
V. A. Are..Sairways properly lettered? V. B. Are flodrsi properly numbered? V. C. Is floor diagram I?
Yes1p< No □ ________ YesOZ No □ Yes □ No S
V. D. Are stairways re-entry V. E. Are elevators properly Ilettered on each V. F. Is floor diagram properly oriented?
Yes
si^s posted?
No □ NZA □
________________________
elevatorV. H.
YesW NoD
bank?Are ।exit doors unlocl^^closed and
N/A □ Yes^ NoD 3
V. G. li elevator sign “In Case of Fire, |‘ v. V. / Fire Drill Organization Charte
use Stairs” posted?
Yes SZ No □ n/aD
unobstructed?
Yes;^ No □
posted and current?
YesJ^L No □ 5
FL^OR
TOTAL (9) rzairni
III. b. Building Inspection—Signs and Charts—Choose one floor for the general floor inspection
V. A. Are inways properly lettered? V. B. Are
properly numbered?
Yes
V. D. Are
No □
irways re-entry
NoD
V. E. Are elevators properly lettered on each
Yes
V. F Is floor diagram property torientM?
3
elev bank?
w.'g.’gs ha d I
V. G. Is elevator sign "In Case of Fire,
Yes' No □ N/A □ Yes^ No □
V. H. Are exit doors unlocked, closed and vzl. Fire Drill Organization Charts
Use Stairs” posted? ..nr.hctr..MoH9
unobstructed? I postcd and current?
Yes □ No □ N/A □ Yesl^ No □ Yes'©^ No Q
TOTAL (9) IO
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 Wdrden within the Building. Read the following
statement to the Warden—‘In the event of a fire on this floor, explain which specific actions must
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Floor Warden have knowledge of:
A. Position duringfire drill or emergency? B. Notification procedures? C. Of alarm boxes?
Yes B No LU Yes 0 No □ No □ NZA □
D. Evaeuation location? E. Evacuatilion prooMures? F. Numter of exits on floor? ^G. Examining for exits on floor?
Yes No □ No □ Yes 0 No □ Yes^ No □_______
H. Repor^g whether smoke or Fire? Duti^of DepuW Fire Warden'and Searchers? V. J. WerZftre drills conducted?
Yes No □_____________ Yes'S No □ Yesy No □
* K. Floorwardens in numerous floors properly trained? Yedi^ No □
TOTAL (11)
Section B: (II. HL IV) 8 or mote 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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