• XYLEM site

  • Conducted on

  • Prepared by

  • Reason for assessment:

  • ​New construction ​

  • Addition to existing structure ​

  • New property acquisition/lease ​

  • Layout/process change ​

  • Evaluation of current fire protection/life safety system ​

  • Other:

Site Description & Activities

  • 1. Describe the location and structures (buildings, size including number of floors, usage, construction, fire ratings). Attach a site map.

  • Add media

  • Is property owned or leased?

  • 2. Number of employees

  • Do any employees work alone? In remote areas?

  • Do visitors (non-employees) ever come on-site?

  • 3. Are any of the following potential sources of ignition present at the site: ​​Welding ​​

  • Brazing ​​

  • Stator-dropping using an open flame/torch ​

  • Heating of parts using an open flame/torch ​ ​

  • Cutting using a flame/plasma arc ​

  • Portable heaters ​

  • Grinding (spark-producing) ​

  • Cooking area. If yes, specify if “normal kitchen” or canteen/cafeteria:

  • If these activities are performed, how will the fire risk be minimized?

  • Describe other heat-generating activities conducted at the location, including any that might use an open flam

  • 4. Describe utilities (electricity, water supply, natural gas):

  • 5. What chemicals are used on-site? Indicate if the chemicals are flammable or combustible and quantities stored.

  • Describe chemical storage and indicate locations on site plan.

  • 6. Has Factory Mutual evaluated the site?

  • recommendations

  • Has the local Fire Department evaluated the site? If yes, recommendations?

Life Safety

  • 7. Does the facility have an evacuation plan? Attach plan or describe. Attach evacuation map.

  • Add media

  • What is the longest travel distance to an emergency exit?

  • How many stories does the building have? Fire escapes from the upper stories?

  • 8. Are evacuation drills conducted periodically? Frequency? Describe alarm system. Is alarm system tested periodically?

  • 9. Are any designated exits not doors? For example, are windows used as emergency exits?

  • Do all emergency exits lead to a place of safety?

  • Are emergency exits always unlocked when premises are occupied? Do doors open in direction of travel?

  • Are escape routes marked and lit? Are emergency exits visible in the dark?

  • 10. What evacuation procedures are in place for visitors?


  • 11. Is there a smoking policy? Designated smoking areas?

  • 12. Is there a Hot Work Program?

  • 13. Have employees been trained on actions to take in the event of a fire?

  • Have employees been trained to use fire extinguishers?

Fire Detection/Fire Fighting Capabilities

  • 14. Is all or part of the facility equipped with smoke detectors? Is the system connected to a central monitoring system?

  • 15. Describe fire-fighting capabilities at the location.

  • Number and type of fire extinguishers:

  • Who services the fire extinguishers? Frequency?

  • 16. Distance to nearest fire department:

  • Mode of alarm:

  • 17. Has the facility ever been involved in a fire? If yes, describe the incident, resulting damages and preventative measures taken.

Financial Assessment

  • 18. Cost to install sprinkler system (attach cost estimate) (Include any required upgrades to water system):

  • 19. Cost of potential losses:

  • Building/property

  • Fixed assets, equipment

  • Stock

  • activity loss (i.e., sales)


  • 20. Please provide your conclusions or recommendations based on the analysis of the information. ( by FM GLOBAL)


  • Site ESH Coordinator:

  • Name

  • Add signature

  • Value Center ESH Manager:

  • Name

  • Add signature

  • Management Company ESH Director:

  • Name

  • Add signature

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.