Monthly Fire and Safety Inspection Form

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Dalhousie University
Monthly Fire and Safety Inspection Form
Building:
_____________________________________________________________
Floor (if applicable):
_____________________________________________________________
Date:
Day: _____ Month: _____ Year: 20_____
Chief Fire Warden:
_____________________________________________________________
Part 1: Obstructions
Status
Comments
Are the hallways clear of debris and
Yes
No
N/A
obstructions?
Are the stairwells clear of debris and
Yes
No
N/A
obstructions?
Are the sprinkler heads free of obstructions?
Yes
No
N/A
An 18h clearance
Are the smoke detectors clear of
Yes
No
N/A
obstructions?
Are the pull stations clear of obstructions?
Yes
No
N/A
Are the telephones clear of obstructions?
Yes
No
N/A
Are the gas shut-offs clear of obstructions?
Yes
No
N/A
Part 2: Doors, Exits, & Lighting
Status
Comments
Are the fire doors closed and latched
Yes
No
N/A
properly?
Are the stairs and floors free of tripping
Yes
No
N/A
hazards such as frayed carpet?
Are the emergency lights working properly?
Yes
No
N/A
Are the EXIT lights working properly?
Yes
No
N/A
Continued on Reverse Side
Dalhousie University
Monthly Fire and Safety Inspection Form
Building:
_____________________________________________________________
Floor (if applicable):
_____________________________________________________________
Date:
Day: _____ Month: _____ Year: 20_____
Chief Fire Warden:
_____________________________________________________________
Part 1: Obstructions
Status
Comments
Are the hallways clear of debris and
Yes
No
N/A
obstructions?
Are the stairwells clear of debris and
Yes
No
N/A
obstructions?
Are the sprinkler heads free of obstructions?
Yes
No
N/A
An 18h clearance
Are the smoke detectors clear of
Yes
No
N/A
obstructions?
Are the pull stations clear of obstructions?
Yes
No
N/A
Are the telephones clear of obstructions?
Yes
No
N/A
Are the gas shut-offs clear of obstructions?
Yes
No
N/A
Part 2: Doors, Exits, & Lighting
Status
Comments
Are the fire doors closed and latched
Yes
No
N/A
properly?
Are the stairs and floors free of tripping
Yes
No
N/A
hazards such as frayed carpet?
Are the emergency lights working properly?
Yes
No
N/A
Are the EXIT lights working properly?
Yes
No
N/A
Continued on Reverse Side
Part 3: Flammables and Combustibles
Status
Comments
Are the hallways and common areas free of
Yes
No
N/A
flammable or combustible materials?
Are the hallways and common areas free of
space heaters (unless approved by the
Yes
No
N/A
University)?
Are appliances or machines that contain
Yes
No
N/A
heating elements unplugged when not in use?
Part 4: Fire Extinguishers
Status
Comments
Have the fire extinguishers been visually
Yes
No
N/A
inspected and the tag initialled?
Are the fire extinguishers hanging and in the
Yes
No
N/A
proper locations?
Part 5: Other
Status
Comments
Are extension cords only being used for
Yes
No
N/A
temporary power?
Are the hallways and common areas free of
holes or other openings, such as missing
Yes
No
N/A
ceiling tiles that could contribute to the
spread of fire?
Are all light switch plates and receptacle
Yes
No
N/A
cover plates in place?
Are accessible electrical panels free of empty
Yes
No
N/A
slots (no breaker or blank plates)?
_________________________________________
_______________________________________
Signature
Date
Keep original copy
Send photocopy to the Safety Office

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