ILSM Evaluation Sheet - FILLABLE-MASTER.pdf

LOCATION: ______________ Interim Life Safety Measures Evaluation Sheet DATE:_______________

A B C D E F G H I J K L M

1 Door locked against egress X X X X X X

2 Lacking a code complying smoke barrier X X X

3 Fire exit stairs discharge improperly X X X X X X

4 Excessive travel distance to an approved exit X X X X

5 Lack of two remote exits X X X X X

6 Nonconforming building construction type X X X X X X

7 Improperly protected vertical openings X X X

8 Large penetrations in fire/smoke barriers X X X X

9 Corridor walls do not extend to the structure X X X X

10 Hazardous areas not properly protected X X

11 Blocking off an approved exit X X X X X X X X

12 Rerouting of traffic to emergency room X X X

13 Major renovation of an occupied floor X X X X X X X X

14 Replacing fire alarm system (out-of-service)* X X X X X X

15 Installing sprinkler system (out-of-service)* X X X X X X X

16 Significantly modifying smoke or fire barrier walls X X X X X

17 Adding an addition to an existing structure X X X X X X X X

18 Taking fire alarm system out-of-service for over 8 hrs* X X X X

19 Taking sprinkler system out-of-service for over 10 hrs* X X X X

20 Disconnecting alarm devices* X X X

Removing ceiling tiles in a sprinklered zone over 10 hrs

(renders sprinklers non-functional)* X X X X

22 ILSM required?

* If yes, attach Fire Watch Decision Grid, Attachment D

Initiator: __________________________ EXT: ________ Safety: _____________________________ Date: ____________ Chief, FMS: _________________________ Date: ____________

Notes

□ Preliminary Evaluation

E m e rg e n c y f o rc e s n o ti fi c a ti o n

Existing Significant Life Safety Code Deficiencies or Conditions as a Result of Construction

E n s u ri n g E g re s s

E m e rg e n c y f o rc e s a c c e s s

VA Sierra Nevada Health Care System

Yes No

C o n d u c ti n g o rg a n iz a ti o n a l tr a in in g o n l if e s a fe ty

C o n tr o lli n g c o m b u s ti b le l o a d in g

C o n d u c ti n g f ir e d ri lls p e r s h if t in a ll a re a s

In c re a s e d h a z a rd s u rv e ill a n c e

C o m p a rt m e n ta liz a ti o n t ra in in g o f p e rs o n n e l

E n s u ri n g o p e ra ti o n a l lif e s a fe ty s y s te m

(p ro v id e f ir e w a tc h i f n e c e s s a ry

T e m p o ra ry c o n s tr u c ti o n b a rr ie rs

A d d it io n a l fi re f ig h ti n g e q u ip m e n t

C o n d u c ti n g a d d it io n a l tr a in in g o f in c id e n t re s p o n s e te a m

P ro h ib it in g s m o k in g