Fire Prevention and Emergency Action Initial Questionnaire This is the initial questionnaire for the Fire Prevention and Emergency Exit Plan Company Information1) Company Name(Required)2) Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 3) Company Phone(Required)4) Type of Business(Required)5) What is the maximum number of employees.(Required)This is the maximum number of employees (part-time or seasonal) you would have during the year.6) Safety Coordinator(Required) First Last 7) Safety Coordinator Email(Required) 8) Safety Coordinator Phone(Required)9) Building Constructed Date(Required)10) Do you have the OSHA poster?(Required) Yes No 11) Does anyone speak secondary language?(Required) Yes No Language(s)Fire Protecion12) Does your building have a sprinkler system?(Required) Yes No Describe systemIs it wet, dry, partial or complete13) What is the method of notification if there is a fire?(Required)Describe the method. For example: Pull Stations, Audible and visual indicators. 14) Do you have any fire extinguishers in your area?(Required) Yes No Who provides the fire extinguishers?15) Are your employees allowed to use the fire extinguishers?(Required) Yes No 16) Do you have any fire extinguishers adjacent to your area ?(Required) Yes No 17) Floor Plan(Required)Max. file size: 128 MB.Provide a copy of the entire floor plan. Include a description or room number for each area. Be sure to include the location of your safe assembly area. This can be a simple sketch.Fire Prevention18) Are there any areas where a large quanity of flammable or combustible chemicals are stored? Yes No Product Name(Required) Add RemoveIndicate the name of the product.Maximum amount stored(Required) Add RemoveProvide the maximum amount stored and units for each productWhere is it stored?(Required) Add RemoveEach productHow is the product used?(Required) Add RemoveIs the product sprayed on something, rolled on something or some other method?Is there fire protection for this area?(Required) Yes No Fire Protection Method(Required)Describe fire protection for the area such as sprinkler system, fire proof cabinet or fire extinguisherIs there any waste generated from the operation?(Required) Yes No How is it handled(Required)19) Is there any heat generating sources (such as portable heaters) nearby?(Required) Yes No Describe heat generating source(Required)20) Is there any source of ignition (Such as candles) in the area?(Required) Yes No Source of Ignition(Required)Describe the source of ignition21) Is there a designated area for smoking?(Required) Yes No Emergency Evaluation22) Are the exits visible from different locations?(Required) Yes No LocationCorrective ActionWhat action is corrected to make exit visible.23) Are they illuminated?(Required) Yes No Corrective ActionLife Safety Code stipulates illumination of about five foot-candles (54 lux) or more at the illuminated surface with a contrast ratio of more than or equal to five-tenths.24) Is the path to the exit uncluttered and free from obstacles?(Required) Yes No Corrective Action25) Is there a door which is not an exit, labeled as “NOT EXIT” or describes what is inside (Such as “Storage").(Required) Yes No Designate Location Add RemoveDescribe corrective action Add Remove26) Are the exit doors easy to open and operate during power outage?(Required) Yes No Location Add RemoveProvide the location of the door.Corrective Action Add RemoveDescribe the problem and any corrective action taken to correct. 27) Do the stairway doors close completely?(Required) Yes No N/A The doors should close completely without any help.Location of stairway door Add RemoveProvide location of door(s)Corrective Action Add RemoveDescribe the corrective actiontakenEvacuation Routes28) Do you have an emergency exit route planned?(Required) Yes No If yes, please provide below. If no, we will work with you to prepare one.29) Are there any flammable material stored in or near the exit route?(Required) Yes No Location Add RemoveProvide each locationCorrective action Add RemoveDescribe the corrective action taken in each location30) Are there any stairways (primary or secondary) in evacuation plan?(Required) Yes No 31) Does your area have a backup route?(Required) Yes No Corrective action32) Are there any items stored under the stairway?(Required) Yes No This would include bicycles.Location(s) Add RemoveCorrective action Add RemoveIn NFPA 101 (2015) Section 7.2.2.5.3 is called Usable Space and states: “Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.” 33) Is the emergency route clearly identified from all locations?(Required) Yes No To make this determination stand at various locations and see if you can find the exit route.Location(s) Add RemoveIndicate each locationDescribe corrective action Add RemoveSafe Assembly Point34) Do you have a safe assembly point been established approximately 50 feet or more from the building?(Required) Yes No Corrective action35) Do you have provisions for handicap individuals?(Required) Yes No Do the employees know how to help handicap employees? Do they know where handicap employees she assemble? Do they know to report presence of handicap individuals to safety coordinator?Corrective actionProvide information about corrective action. If additional space is needed attach at end of questionnairte.36) Is the safe assembly area clearly identified?(Required) Yes No Corrective action37) Does the Safety Coordinator and designee have a current list of all employees?(Required) Yes No Corrective actionConstruction Activity38) Is there any construction activity in your area or in your exit route? Yes No ActivityIf there is any construction in your area or in your exit route be sure the contractor has a fire prevention plan in place. For example, painting – are they using any flammable or combustible materials, Ceiling replacement – do they have a fire watch to prevent fires from spreading; flame producing operations – do they have a hot work program with fire watch. If not for your area require one be submitted, if rental in building, recommend to building owner.Responsibilities39) Do the employees know their responsibility in exiting the building?(Required) Yes No 40) Do the employees know the procedures for handicap or visiting individuals?(Required) Yes No Corrective actionCorrective action41) Does the Safety Coordinator designee know their rersponsibilities?(Required) Yes No Corrective actionAdditional InformationIf you have an existing plan, please provide a copy.Accepted file types: pdf, docx, doc, jpeg, jpg, Max. file size: 128 MB.Do you have any additional information about the Fire Prevention and Emergency Exit Plan.This field is hidden when viewing the formQuestionnaire
