NYC 9/11 Public Portal Document
-A a “NO” answers to a “V” mandati
A this form must have an answer. Answers^Bh
Instructions to Inspectors—All boxes^^
Violation Order, “NO” answers to a mandate aut^Rtic failure. Check “YES” “NO” or “N/A’
ON SITE EXAM FOR
FIRE SAFETY DIRECTOR—OFFICE
Z 01 &S Infipftrtnr to
Jame of r.anHidatBCo'^n.l<S>-<\r-J , J/MV\g.^ Office Address ftt-oC bg. CgiLJi eft, gate of Examination IG S
(Print last name, first name)
lOOM e>
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 cqpective devices) (corrective devices acceptable)
Yes -0^ No □ Yes0 NoD Yes Er 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 dr(U records current?! v. B- Firem^s Service Elevator Test Records current?| v. C. Keys kejrt at Fire Command Station?
Yes No □ No □ N/A □ Yes 0^ No □ N/A □ 3
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 a^re Command Station? numbers at Fire Command Station? N/A 0^
Yes 0 No □ Yes 0 No D Yes □ No □
V. G. Building current in actual Fire Drills? (*if over 3 months) Yes 0 No D
________________ ___________________________________________________________________________________ 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. 34
FLOOR
Building Inspection—Signs and Charts—
V. A. Are gjrways goperly lettered? V. B. Are floqrd' properly numbered? V. C. Is flooj^iagramposted?
Yes Yes 0 No □ Yes 0 No □ 5
V. D. Are stairways re-entry V. E. Are elevators properly lettered on each V. F. Is floor diagram properly oriented?
signs posted? elevatoGbank? 3
Yes 0 No □ N/A □ Yes ^0 NoD N/A □ Yes 0^ No □
V. G. Is elevator sign "In Case of Fire, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Sterfo'-' posted?
Yes 0 No D N/A D
unobstmeted?
Yes 0 No □
posted Md current?
Yes 0 No □ 5
TOTAL (9)
III. b. Building Inspection—Signs and Chaits—Choose one floor for the general floor inspection 3:___
FLOOR
V. A. Are stairways properly lettered? V. B. Are floors properly numbered? V. C. Is floo^iagram posted?
Yes 0 No □ Yes 0 NoD Yes 0 No □ 3
V. D. Are stairways re-entry w. E. Are elevators jjroperly lettered on each V. F. Is floor diagram properly oriented?
signs^xrsted? eleval .bank*
Yes Sr No □ N/A □ No □ N/A □ Yes 0^ No □
Yes
V. G. Is elevator sign “In Case of Rre, V. H. Are exit doors unlocked, closed and V. I. Fire Drill Organization Charts
Use Stairs” posted? unobs^cted? posted Md current?
Yes [3^ No □ N/A □ Yes 0 No □ Yes 0 No □
3
___________ _____________________________________________________________________ ____________________ TOTAL (9) A
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 Roor 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:
COLuaJS , JgfZXMtAtA 3M
NAME OF FLOOR WARDEN CONTACTED FLOOR CHOSEN TELEPHONE NUMBER
Does Roor Warden have knowledge of:
A. Position, during fire drill or emergency? B. Notific^on procedures? C. Location of alarm boxes?
Yes 0 No □ Yes 0 No D Yes 0 No □ N/A □ 3
D. Evacuation location? E. Evacuation procedures? F. Num^ of exits on floor? G. Examining for exits on floor?
Yes 0 No □ Yes 0 No D Yes M No □ Yes 0 No □ 4
H. Reportipg whether smoke or Fire? I. Duties^ Deputy Fire Warden and Searchers? V. J. Wereflj-e drills conducted?
Yes 0 No □ Yes 0 No U Yes 0 No □ 3
*K. Floor wardens in numerous floors properly trained? Yes 0 No D
TOTAL (11) i I
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 3 Lo . Number of incorrect answers is — . Number of N/A answers is
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