Quarterly Test & Inspection Site Evacuation System Certificate

• Client:

• Site Name (Phase/Block):

• Contract Number:

• Date:

  Date

• Carried out by:

• Inspection Type

  Quarterly Inspection

  Annual Inspection

System Inspection/Servicing Report

• Extent of the evacuation system covered by this report:

• Agreed Limitation, if any, on the inspection and servicing:

QUARTERLY TEST / INSPECTION

• Visual devices check

  Yes

  No

  N/A

• Devices accessbible

  Yes

  No

  N/A

• All Zones seen by Control Panel

  Yes

  No

  N/A

• All Devices seen by Control Panel

  Yes

  No

  N/A

• Devices schedule displayed

  Yes

  No

  N/A

• Control Panel standby power supplies provided (mains voltage)

  Yes

  No

  N/A

• Log Book records checked

  Yes

  No

  N/A

• Devices LED test completed

  Yes

  No

  N/A

• Audible evacuation test completed

  Yes

  No

  N/A

• Audible First Aid test completed (where applicable)

  Yes

  No

  N/A

• Check control panel History log

  Yes

  No

  N/A

• Devices checked for correct operation (25%)

  Yes

  No

  N/A

• Devices standby power supplies (battery check)

  Yes

  No

  N/A

• Auto dialer operational (where applicable)

  Yes

  No

  N/A

ANNUAL TEST / INSPECTION

• Switch mechanism of every call point over 12 month period

  Yes

  No

  N/A

• All devices checked for correct operation over 12 month period

  Yes

  No

  N/A

• Control Panel standby power supplies provided (mains voltage)

  Yes

  No

  N/A

• All devices standby power supplies (battery check)

  Yes

  No

  N/A

• Log Book records checked

  Yes

  No

  N/A

• Log book available

  Yes

  No

  N/A

I/we declare that in my/our judgement, the said system was in overall in the below stated condition at the time the inspection and servicing was carried out, and that it should be further inspected as recommended (see below). * (Insert 'a satisfactory' or 'an unsatisfactory' as appropriate):

• Satisfactory

  Unsatisfactory

  N/A

  Requires Improvement

• Full Name

• Signature

  Sign

• Position

• Date

  Date

Summary of Inspection & Servicing

• (Insert comments as necessary)

• Number of outstanding defects reported to responsible person