Fire Prevention and Emergency Action Monthly Questionnaire This is the monthly questionnaire for the Fire Prevention and Emergency Exit Plan for locations without fire extinguishers and mandatory employee evacuation. 1) Company Name(Required)2) Safety Coordinator(Required) First Last 3) Safety Coordinator Email(Required) 4) Safety Coordinator Phone(Required)6) Name of individual conducting inspection(Required) First Last 7) Date of Inspection(Required) MM slash DD slash YYYY 8) Were there any changes made since last inspection?(Required)For example new safety coordinator, additional space, change in function of room(s)Floor Plan, only provide new if changesMax. 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 Prevention9) Have there been any changes in your fire prevention. plan?(Required) Yes No Explain Any ChangesEmergency Exits10) Are the exits visible from different locations?(Required) Yes No LocationCorrective Action11) 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.12) Is the path to the exit uncluttered and free from obstacles?(Required) Yes No 13) Is there a door which is not an exit, labeled as “NOT EXIT” or describes what is inside (Such as “Storage").(Required) Yes No Corrective ActionCorrective Action14) Are the exit doors easy to open and operate during power outage?(Required) Yes No 15) Do the stairway doors close completely?(Required) Yes No N/A The doors should close completely without any help.Corrective ActionCorrective ActionEvacuation Routes16) Are there any flammable material stored in or near the exit route?(Required) Yes No 17) Are there any items stored under the stairway?(Required) Yes No This would include bicycles.Corrective ActionCorrective ActionIn 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.” 18) 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.Corrective ActionSafe Assembly Point19) Is the safe assembly area clearly identified?(Required) Yes No 20) Does the Safety Coordinator and designee have a current list of all employees?(Required) Yes No Corrective ActionCorrective ActionConstruction Activity21) Is there any construction activity in your area or exit route?(Required) 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.Responsibilities22) Do the employees know their responsibility in exiting the building?(Required) Yes No 23) Do the employees know the procedures for handicap or visiting individuals?(Required) Yes No Corrective ActionCorrective Action24) Does the Safety Coordinator designee know their rersponsibilities?(Required) Yes No Corrective ActionAdditional InformationDo you have any additional information about the Fire Prevention and Emergency Exit Plan?
