Clinic Fire and Life Safety Survey

• Address and Suite #

• UTP Clinic Name

• Visited on

  Date

• Prepared by

MEANS OF EGRESS

• Are all DOOR requirements met, i.e. clearance and hardware?

  Yes

  No

  N/A

• Are all EXIT SIGNS installed correctly, i.e. directional arrows and illuminated?

  Yes

  No

  N/A

• Are STAIRS accessible and meet minimum requirements?

  Yes

  No

  N/A

• Are MEANS OF EGRESS free and clear?

  Yes

  No

  N/A

• Is INTERIOR FINISH acceptable?

  Yes

  No

  N/A

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  Media

• Other comments:

FIRE NOTIFICATION SYSTEMS

• Is there a FIRE NOTIFICATION system?

  Yes

  No

  N/A

• Are SMOKE & HEAT DETECTORS installed in require locations? (N/A if fully covered with approved automatic sprinkler system.)

  Yes

  No

  N/A

• Are manual PULL STATIONS provided at exit doors? Do they meet distance requirements? (N/A if fully covered with approved automatic sprinkler system.)

  Yes

  No

  N/A

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• Other comments:

FIRE SUPPRESSION SYSTEMS

Personal Fire Extinguishers (PFE)

• Name of PFE inspection company?

• Was ANNUAL inspection completed?

  Yes

  No

  N/A

• Date of inspection?

  Date

• Are MONTHLY inspections completed?

  Yes

  No

  N/A

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  Media

• Other comments:

Fire Sprinkler System

• Is there a FIRE SPRINKLER system?

  Yes

  No

  N/A

• Name of fire sprinkler company?

• Date of inspection?

  Date

• Is there 18" of ceiling clearance and no sprinkler obstructions?

  Yes

  No

  N/A

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  Media

• Other comments:

ELECTRICAL

Emergency Lighting

• Is emergency LIGHTING present and operational?

  Yes

  No

  N/A

• How is emergency lighting POWERED?

  Battery

  Generator

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• Other comments:

Electrical Componets

• Are ELECTRICAL COMPONENTS free of visible damage and have proper covers?

  Yes

  No

  N/A

• Are POWER STRIPS properly supported and not daisy chained?

  Yes

  No

  N/A

• Do personal SPACE HEATERS meet guidelines?

  Yes

  No

  N/A

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• Other comments:

MISCELLANEOUS

• Are alcohol-based hand sanitizer DISPENSERS present?

  Yes

  No

  N/A

• Is the location of DISPENSERS compliant, ie clearance and electrical proximity?

  Yes

  No

  N/A

• Is there less than 10 gallons of alcohol-based sanitizer in STORAGE?

  Yes

  No

  N/A

• Is an Automatic External Defibrillator (AED) present with current battery and pads?

  Yes

  No

  N/A

• Is the AED inspected (tag or log)?

  Yes

  No

  N/A

• Is an EMERGENCY EYE WASH present and correctly installed?

  Yes

  No

  N/A

• Is the eye wash inspected (tag or log)?

  Yes

  No

  N/A

• Are mechanical/electrical/data rooms free of storage?

  Yes

  No

  N/A

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• Other comments: