Title Page
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Document No.
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Premises Name
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Client
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Conducted on
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Prepared by
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Add drawing
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Add drawing
Contact Details
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Address
Contract Persons
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Name
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Tel.no.
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Mob. no.
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Email address
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Title
- CNM1
- CNM2
- CNM3
- ADON
- Manager
- Services Manager
- Director of Nursing
- Other
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If other. Place title in box below
Occupants
- Area
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- p Whole Premises
- Floor
- Ward
- Section
- Department
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Business Hours
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Staff day
- 0
- 1
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- 8
- 9
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- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Staff Night
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Staff Sleeping
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Service Users day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Service Users Night
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Service Users Sleeping
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
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Service Users Non-ambulant
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Number
Fire Safety Measures
Fire alarm panel
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Location
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What type is it
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Is it monitored
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Provide contact details
Repeater panels
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Is there a repeater panel in this area
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Location
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Notes
Fire exits
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Location
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Type of lock
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Is there a key box
Manual call points
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Location
Hydrants
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Location
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Flow
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Pressure
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Hyd no
- 0
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- 8
- 9
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- 17
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- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
Building Details
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Storeys
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- >30 (see below)
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Construction
- Standard
- Timber
- Modular
- Steel FrameMass Concrete
- Temporary
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Roof
- Concrete tile
- Slate
- Get Felt
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Vehicular Access
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Are there any gates
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Location
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Are they locked
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What are arrangements for opening gates
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Are there any key codes
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Codes
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Are there any height restrictions
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Itemise restriction
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Preferred route
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Services Oil
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Is there an oil fired boiler house
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Location
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Oil tank location
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Oil tank capacity in litres
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Sketch
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Notes
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Is there automatic fire suppression above burner
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Type
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Notes
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Services Gas
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Is there a gas fueled boiler house
Location of boiler house
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Location
Location of shut off
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Location
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Add drawing
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Notes
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Is there LPG on site
Location of LPG Tank
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Add media
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Add drawing
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Location
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Capacity
Location of shut offs
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Add drawing
Services Electrical
- Shut off location
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Location
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Voltage
- 220V
- 340V
- High Voltage
- Other (see notes)
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Add drawing
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Notes
Hazardous Substance
Oxygen
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UN Number 1234
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Is there a tank
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Location
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Capacity
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Add media
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Add drawing
Oxygen cylinders UN No. 1234
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Location
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Size of cylinder
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Number of cylinders
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Add media
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Add drawing
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Notes
Nitrous oxide cylinders UN No
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Location
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Size of cylinder
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Number of cylinders
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Add media
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Add drawing
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Notes
Medical Air UN No.
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Location
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Size of cylinders
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Number of cylinders
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Add media
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Add drawing
- Other Hazardous Substances
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Substance name
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UN Number
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Quantity
Salvage
- Item
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Location
