Life Safety Specialist Documentation Checklist

Healthcare Facility: ______Date: ______

1. Electronic Statement of Condition Documents (e-SOC):

BBI Building Description / Occupancy Class / Completion Date
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D
B A H H/D

Comments:

LSA Building Description / Date Completed / Comments

Comments:

1

e-SOC, continued

PFI Building Description / Items Completed / Items Not Completed / Items in Default

Comments:

Interim Life Safety Measures (ILSM) evaluated for PFI’s? Y N

Color-coded compartmentation prints available? Y N Accurate? Y N

Previously accepted/ signed e-PFI form available? Y N

Building Maintenance Program (BMP)? Y N Effectiveness Measured? Y N

Above-the-Ceiling (ATC) permit program? Y N Implemented? Y N

Comments:

2

2. Fire System Documentation and Test Results

Component Description / Responsibility / Test
Interval / Documentation
Comments / Test Result
Supervisory devices / IH CON / Q / P F
Tamper switches / IH CON / S/A / P F
Water flow devices / IH CON / S/A / P F
Duct detectors / IH CON / A / P F
Mag. release devices / IH CON / A / P F
Heat detectors / IH CON / A / P F
Pull boxes / IH CON / A / P F
Smoke detectors / IH CON / A / P F
Visible devices / IH C ON / A / P F
Audible devices / IH CON / A / P F
Off-site responders / IH CON / Q / P F
Fire pump (churn) / IH CON / W / P F
Fire pump (dischge) / IH CON / A / P F
Water tank level alms / IH CON / S/A / P F
Water tank (winter) / IH CON / M / P F
Riser drain test / IH CON / A / P F
Fire dept connections / IH CON / Q / P F
Standpipe flow test / IH CON / 5 YR / P F
Kitchen systems / IH CON / S/A / P F
Gas/ CO2 systems / IH CON / A / P F
Port extinguishers / IH CON / M / P F
Port extinguishers / IH CON / A / P F
Occupant hoses / IH CON / 5/3 YR / P F
F/S dampers / IH CON / 1/6 YR / P F
Air handler shutdown / IH CON / A / P F
H/V fire doors / IH CON / A / P F
IH CON / P F
IH CON / P F

Test results Maintained in Binders or Folders? Y N

Documents in same order as checklist? Y N

Vendor reports timely? Y N

Deficiencies corrected on a timely basis? Y N

Comments:

3

3. Electrical System Documentation and Test Results

Generator Location / Full Load Rating (KW) / Monthly Test w/ 30% Load / Transfer Switch Tests / Comments

Trienniel test? Y N Date of Test: ______

Fuel oil quality check? Y N Date of Test: ______

Battery lights installed in emergency generator/ switchgear rooms? Y N

Monthly 30-second test performed and documented? Y N

Battery lights installed in anesthetizing locations? Y N

Monthly 30-second test performed and documented? Y N

Battery lights installed in outpatient clinics without generators? Y N

Monthly 30-second and annual 90-minute tests performed and documented? Y N

Level I UPS system installed? Y N

Quarterly (5-minute) and Annual (60%) test Documentation? Y N

Comments:

4

4. Medical Gas and Vacuum System Documentation and Test Results

Component Description / Test Responsibility / PM Test Procedures? / Adequate Documentation? / Comments
Source tanks / IH CON
Source valves / IH CON
Manifolds / IH CON
Medical air compressor / IH CON
Medical vacuum pump / IH CON
Zone valves / IH CON
Master alarms / IH CON
Area/ local alarms / IH CON
Medical gas outlets / IH CON
Outlet labeling / IH CON
Medical air quality / IH CON
Medical gas quality (O2) / IH CON

New construction/ renovation test results? Y N

Certification from third-party? Y N

Comments:

5

5. Interim Life Safety Measures (ILSM)

ILSM policy exists? Y N

Policy describes when ILSM evaluation is required for the following?

● Construction/ renovation? Y N

● Life safety compromised? Y N

● PFI’s issued? Y N

● Work orders issued? Y N

● Exceptions to ILSM evaluation in policy? Y N

Applicability of ILSM measures documented? Y N

Documentation of implemented measures? Y N

Daily/ periodic inspections in work area documented? Y N

Comments:

6. Additional Comments:

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