Colliers International - Fire Services Impairment Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Step One – Contractor to complete

• Property Address:
  Address

• Colliers Personnel Requesting Work:

• Name of Contractor’s company:

• Contractor’s name and mobile phone number:

• Date and time work to commence:

  Date

• Date and time work to cease:

  Date

• 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:

  Sign

• Date and time:

  Date

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:

• I DECLARE THAT I HAVE BEEN ADVISED THAT THE FIRE SYSTEMS HAVE BEEN FULLY RESTORED.

• Signature:

  Sign

• Title:

• Date:

  Date