• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Step One – Contractor to complete

  • Property Address:
  • Colliers Personnel Requesting Work:

  • Name of Contractor’s company:

  • Contractor’s name and mobile phone number:

  • Date and time work to commence:

  • Date and time work to cease:

  • Describe nature of fire protection impairment: sprinklers/hydrants/fire detection system) and area affected:

Reason for impairment: Tick the box describing the purpose of the work that requires the fire services impairment:

  • Shop Fit out

  • Repairs

  • Maintenance

  • Emergency

PRECAUTIONS TO BE TAKEN Tick the box(es) describing the precautions to be taken:

  • Helpdesk / Site Security Notified

  • Fire Extinguisher on hand

  • Tenant Notified

  • Ongoing Patrol of Impairment Area

  • Fire Hoses Laid Out

  • Hydrant Connected to Sprinkler Riser

  • Pipe Plugs on hand

  • Hazardous Operations Stopped e.g. cutting/welding

  • Smoking Restricted

  • Impairment area minimised (i.e. not entire floor)

If sprinkler system impaired, the following equipment must be put back on line:

  • Diesel/Electric pump

  • Fire Indicator Panel

  • Valves restored to normal operating condition

Restoration of Fire Sprinkler Services

  • A 50mm running test of fire sprinkler services will be undertaken after restoring protection completed to ensure that valves are fully open.

Step Two – Colliers International REM to email this form to the following: *The Colliers International REM person who is the controller of this impairment process *Colliers International REM insurers *The relevant Fire Services Monitoring Company

  • I authorise that the fire services may be isolated based on the implementation of the control measures detailed in section one of this fire services impairment form.

  • Signed:

  • Date and time:

Step Three – The Colliers International REM Controller is responsible for contacting the contractor at cease date and time documented in Step One to ensure the work has been completed:


  • Signature:

  • Title:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.