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Self-Inspection Checklist

Steps

1. Step One (current) This section is complete This section is incomplete
2. CHECK LIST This section is complete This section is incomplete

Step One

Self-Inspection Checklist
ADDRESS:*
SUITE #:
BUSINESS NAME:*
BUSINESS PHONE:*
BUSINESS FAX:
EMAIL:
INSURANCE NAME/CONTACT PERSON:*
PHONE #:*
BUILDING OWNER NAME (IF DIFFERENT THAN BUSINESS OWNER):
PHONE #:
MOBILE #:
EMAIL:
BUSINESS OWNER:*
PHONE #:*
MOBILE #:*
EMAIL:*
EMERGENCY CONTACT #1:
TITLE #1:
PHONE #:
MOBILE #:
EMAIL:
EMERGENCY CONTACT #2:
TITLE #2:
PHONE #:
MOBILE #:
EMAIL:
Continue

CHECK LIST

LIFE SAFETY
1. Are Exit Lights illuminated at all times? (Please press Test Button) *
2. Do Exits all have clear access?*
3. Are Emergency lighting units working? (Please press Test Button) *
4. Is panic hardware operational?*
5. Are exits unlocked or unbarred when occupied?*
6. Exit doors easily opened?*
FIRE PROTECTION SYSTEM(S)
1. Is the building equipped with a fire alarm?*
2. Is fire alarm system inspected by a licensed fire alarm contractor?
Date Tested:
Date Tested:
3. Are smoke detectors operable? (Please test)
4. If required, has the fire sprinkler system been inspected?
SPRINKLER SYSTEM TESTED:
SPRINKLER SYSTEM TESTED:
5. If required, has the hood suppress system been inspected?
HOOD SUPPRESSION SYSTEM TESTED:
HOOD SUPPRESSION SYSTEM TESTED:
6. If required, has the hood cleaning been completed?
DATE HOOD WAS CLEANED:
DATE HOOD WAS CLEANED:
7. If required, has the fire door been inspected?
DATE FIRE DOOR TESTED:
DATE FIRE DOOR TESTED:
Please send copies of Fire Alarm, Sprinkler, Hood Suppression, Hood Cleaning & Fire Door inspection reports
You may fax or email copies also. Fax number is 574-272-4043 or crrd@clayfd.com
8. Have the Fire Extinguisher(s) been inspected in the last year? (yearly inspection required)*
9. Are Fire Extinguisher(s) hung on proper brackets?*
ELECTRICAL
1. Do all Receptacle/switches have covers?*
2. Does the Electrical panel have clear access (30”x36” Clear)*
3. Are extension cords used for temporary or portable equipment ONLY?*
4. All openings in the electrical panel covered?*
5. Are all receptacles, switch or circuit breakers in working order?*
CONDITIONS WHICH MAY CAUSE FIRE SPREAD
1. Are all walls, ceilings, and floors clear of any holes?*
2. Is all storage 24” below ceiling?*
3. Are all flammable liquids properly stored?*
4. Are all Combustible liquids properly stored?*
5. Are all oil Covered rags properly stored?*
6. Are Compressed gas cylinders chained?*
7. All combustible material away from heat sources?*
8. All pipe chases/holes with filled with non-combustible material?*
MISCELLANEOUS
1. Are the Address & Suite numbers visible from the road? Also, on back door?*
2. Are fire lanes unobstructed?*
3. Is the yard around your business free of overgrowth and debris?*
FIRE SAFETY EDUCATION
Is a written fire evacuation plan provided?
Do employees have knowledge of Extinguishers type and use?
Do employees have knowledge of Evacuation procedures?
Do employees have knowledge of Hazardous materials? (MSDS, handling, storage, etc.)
Request more information on the Knox Box Rapid Entry System. (www.knoxbox.com)
Request Fire Extinguisher or emergency planning/evacuation Training.
Request a follow-up call from the Community Risk Reduction Division.
COMMENTS:
PRINT NAME OF PERSON COMPLETING INSPECTION:*
DATE COMPLETED:*
DATE COMPLETED:

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Self-Inspection Checklist

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CHECK LIST

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