02_TL_5.4.5_Fire_Alarm_System.docx

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Facilities Maintenance Services at Fort McCoy, WI
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W912ES-17-R-0002
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02 TL 5.4.5

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FIRE ALARM and Emergency communication system inspection and testing form To be completed by the system inspector or tester at the time of the inspection or test.

It shall be permitted to modify this form as needed to provide a more complete and/or clear record.

Insert N/A in all unused lines.

Attach additional sheets, data, or calculations as necessary to provide a complete record.

Date of this inspection or test:
Time of inspection or test:
1.PROPERTY INFORMATION
Name of property:
Address:
Description of property:
Occupancy type:
Name of property representative:
Address:
Phone:
Fax:
E-mail:
Authority having jurisdiction over this property:
Phone:
Fax:
E-mail:
2.INSTALLATION, SERVICE, AND TESTING CONTRACTOR INFORMATION
Service and/or testing organization for this equipment:
Address:
Phone:
Fax:
E-mail:
Service technician or tester:
Qualifications of technician or tester:
A contract for test and inspection in accordance with NFPA standards is in effect as of:
The contract expires:
Contract number:
Frequency of tests and inspections:
Monitoring organization for this equipment:
A contract for test and inspection in accordance with NFPA standards is in effect as of:
Address:
Phone:
Fax:
E-mail:
Entity to which alarms are retransmitted:
Phone:
3.TYPE OF SYSTEM OR SERVICE
|_| Fire alarm system (nonvoice)

|_| Fire alarm with in-building fire emergency voice alarm communication system (EVACS)

|_| Mass notification system (MNS)

|_| Combination system, with the following components:

|_| Fire alarm |_| EVACS |_| MNS |_| Two-way, in-building, emergency communication system

|_| Other (specify):
3.TYPE OF SYSTEM OR SERVICE (continued)
NFPA 72 edition:
Additional description of system(s):
3.1Control Unit
Manufacturer:
Model number:

3.2 Mass Notification System |_| This system does not incorporate an MNS

3.2.1 System Type:

|_| In-building MNS—combination

|_| In-building MNS—stand-alone|_| Wide-area MNS|_| Distributed recipient MNS
|_| Other (specify):

3.2.2 System Features:

|_| Combination fire alarm/MNS|_| MNS ACU only|_| Wide-area MNS to regional national alerting interface
|_| Local operating console (LOC)|_| Direct recipient MNS (DRMNS)|_| Wide-area MNS to DRMNS interface
|_| Wide-area MNS to high-power speaker array (HPSA) interface|_| In-building MNS to wide-area MNS interface
|_| Other (specify):

3.3 System Documentation

|_| An owner’s manual, a copy of the manufacturer’s instructions, a written sequence of operation, and a copy of the record

record drawings are stored on site.
Location:
3.4System Software|_| This system does not have alterable site-specific software.
Software revision number:
Software last updated on:
|_| A copy of the site-specific software is stored on site. Location:
4.SYSTEM POWER
4.1Control Unit

4.1.1 Primary Power

Input voltage of control panel:
Control panel amps:
4.1.2 Engine-Driven Generator|_| This system does not have a generator.
Location of generator:
Location of fuel storage:
Type of fuel:
4.1.3 Uninterruptible Power System|_| This system does not have UPS.
Equipment powered by a UPS system:
Location of UPS system:

Calculated capacity of UPS batteries to drive the system components connected to it:

In standby mode (hours):
In alarm mode (minutes):

4. SYSTEM POWER (continued)

4.1.4 Batteries

Location:
Type:
Nominal voltage:
Amp/hour rating:

Calculated capacity of batteries to drive the system:

In standby mode (hours):
In alarm mode (minutes):

|_| Batteries are marked with date of manufacture.

4.2 In-Building Fire Emergency Voice Alarm Communication System or Mass Notification System |_| This system does not have an EVACS or MNS.

4.2.1 Primary Power

Input voltage of EVACS or MNS panel:
EVACS or MNS panel amps:
4.2.2 Engine-Driven Generator|_| This system does not have a generator.
Location of generator:
Location of fuel storage:
Type of fuel:
4.2.3 Uninterruptible Power System|_| This system does not have a UPS.
Equipment powered by a UPS system:
Location of UPS system:
In standby mode (hours):
In alarm mode (minutes):

4.2.4 Batteries

Location:
Type:
Nominal voltage:
Amp/hour rating:
In standby mode (hours):
In alarm mode (minutes):

4.3 Notification Appliance Power Extender Panels |_| This system does not have power extender panels.

4.3.1 Primary Power

Input voltage of power extender panel(s):
Power extender panel amps:
4.3.2 Engine-Driven Generator|_| This system does not have a generator.
Location of generator:
Location of fuel storage:
Type of fuel:
4.3.3 Uninterruptible Power System|_| This system does not have a UPS.
Equipment powered by a UPS system:
Location of UPS system:
In standby mode (hours):
In alarm mode (minutes):

4. SYSTEM POWER (continued)

4.3.4 Batteries

Location:
Type:
Nominal voltage:
Amp/hour rating:
In standby mode (hours):
In alarm mode (minutes):

5. ANNUNCIATORS |_| This system does not have annunciators.

5.1 Location and Description of Annunciators

Annunciator 1:
Annunciator 2:
Annunciator 3:
6.NOTIFICATIONS MADE PRIOR TO TESTING
Monitoring organization
Contact:
Time:
Building management
Contact:
Time:
Building occupants
Contact:
Time:
Authority having jurisdiction
Contact:
Time:
Other, if required
Contact:
Time:
7.TESTING RESULTS
7.1Control Unit and Related Equipment
Description
Visual Inspection
Functional Test
Comments
Control unit
|_|
|_|
Lamps/LEDs/LCDs
|_|
|_|
Fuses
|_|
|_|
Trouble signals
|_|
|_|
Disconnect switches
|_|
|_|
Ground-fault monitoring
|_|
|_|
Supervision
|_|
|_|
Local annunciator
|_|
|_|
Remote annunciators
|_|
|_|
Power extender panels
|_|
|_|
Isolation modules
|_|
|_|
Other (specify)
|_|
|_|
7.TESTING RESULTS (continued)
7.2Control Unit Power Supplies
Description
Visual Inspection
Functional Test
Comments
120-volt power
|_|
|_|
Generator or UPS
|_|
|_|
Battery condition
|_|
|_|
Load voltage
|_|
|_|
Discharge test
|_|
|_|
Charger test
|_|
|_|
Other (specify)
|_|
|_|
7.3In-Building Fire Emergency Voice Alarm Communications Equipment
Description
Visual Inspection
Functional Test
Comments
Control unit
|_|
|_|
Lamps/LEDs/LCDs
|_|
|_|
Fuses
|_|
|_|
Primary power supply
|_|
|_|
Secondary power supply
|_|
|_|
Trouble signals
|_|
|_|
Disconnect switches
|_|
|_|
Ground-fault monitoring
|_|
|_|
Panel supervision
|_|
|_|
System performance
|_|
|_|

Sound pressure levels Occupied |_| Yes |_| No

|_|
|_|
Ambient
dBA
Alarm
dBA

(attach report with locations, values, and weather conditions)

System intelligibility

|_| CSI |_| STI

(attach report with locations, values, and weather conditions)

|_|
|_|
Other (specify)
|_|
|_|
7.TESTING RESULTS (continued)
7.4Notification Appliance Power Extender Panels
Description
Visual Inspection
Functional Test
Comments
Lamps/LEDs/LCDs
|_|
|_|
Fuses
|_|
|_|
Primary power supply
|_|
|_|
Secondary power supply
|_|
|_|
Trouble signals
|_|
|_|
Ground-fault monitoring
|_|
|_|
Panel supervision
|_|
|_|
Other (specify)
|_|
|_|
7.5Mass Notification Equipment
Description
Visual Inspection
Functional Test
Comments
Functional test
|_|
|_|
Reset/power down test
|_|
|_|
Fuses
|_|
|_|
Primary power supply
|_|
|_|
UPS power test
|_|
|_|
Trouble signals
|_|
|_|
Disconnect switches
|_|
|_|
Ground-fault monitoring
|_|
|_|
CCU security mechanism
|_|
|_|
Prerecorded message content
|_|
|_|
Prerecorded message activation
|_|
|_|
Software backup performed
|_|
|_|
Test backup software
|_|
|_|
Fire alarm to MNS interface
|_|
|_|
MNS to fire alarm interface
|_|
|_|
In-building MNS to wide-area MNS
|_|
|_|
7.TESTING RESULTS (continued)
7.5Mass Notification Equipment (continued)
Description
Visual Inspection
Functional Test
Comments
MNS to direct recipient MNS
|_|
|_|

Sound pressure levels Occupied |_| Yes |_| No

|_|
|_|
Ambient
dBA
Alarm
dBA

(attach report with locations, values, and weather conditions)

System intelligibility

|_| CSI |_| STI

(attach report with locations, values, and weather conditions)

|_|
|_|
Other (specify)
|_|
|_|
7.6Two-Way Communications Equipment
Description
Visual Inspection
Functional Test
Comments
Phone handsets
|_|
|_|
Phone jacks
|_|
|_|
Off-hook indicator
|_|
|_|
Call-in signal
|_|
|_|
System performance
|_|
|_|
System audibility
|_|
|_|
System intelligibility
|_|
|_|
Radio communications enhancement system
|_|
|_|
Area of refuge communication system
|_|
|_|
Elevator emergency communications system
|_|
|_|
Other (specify)
|_|
|_|
7.TESTING RESULTS (continued)
7.7Combination Systems
Description
Visual Inspection
Functional Test
Comments
Fire extinguishing monitoring devices/system
|_|
|_|
Carbon monoxide detector/system
|_|
|_|
Combination fire/security system
|_|
|_|
Other (specify)
|_|
|_|
7.8Special Hazard Systems
Description (specify)
Visual Inspection
Functional Test
Comments
|_|
|_|
|_|
|_|
|_|
|_|
7.9Emergency Communications System
|_|Visual
|_|Functional
|_|Simulated operation
|_|Ensure predischarge notification appliances of special hazard systems are not overridden by the MNS.
See NFPA 72, 24.4.1.7.1.

7.10 Monitored Systems

Description (specify)
Visual Inspection
Functional Test
Comments
Engine-driven generator
|_|
|_|
Fire pump
|_|
|_|
Special suppression systems
|_|
|_|
Other (specify)
|_|
|_|

7. TESTING RESULTS (continued)

7.11 Auxiliary Functions

Description
Visual Inspection
Functional Test
Comments
Door-releasing devices
|_|
|_|
Fan shutdown
|_|
|_|
Smoke management/smoke control
|_|
|_|
Smoke damper operation
|_|
|_|
Smoke shutter release
|_|
|_|
Door unlocking
|_|
|_|
Elevator recall
|_|
|_|
Elevator shunt trip
|_|
|_|
MNS override of FA signals
|_|
|_|
Other (specify)
|_|
|_|

7.12 Alarm Initiating Device

|_| Device test results sheet attached listing all devices tested and the results of the testing

7.13 Supervisory Alarm Initiating Device

|_| Device test results sheet attached listing all devices tested and the results of the testing

7.14 Alarm Notification Appliances

|_| Appliance test results sheet attached listing all appliances tested and the results of the testing

7.15 Supervisory Station Monitoring

Description
Visual Inspection
Functional Test
Time
Comments
Alarm signal
|_|
|_|
Alarm restoration
|_|
|_|
Trouble signal
|_|
|_|
Trouble restoration
|_|
|_|
Supervisory signal
|_|
|_|
Supervisory restoration
|_|
|_|
8.NOTIFICATIONS THAT TESTING IS COMPLETE
Monitoring organization
Contact:
Time:
Building management
Contact:
Time:
Building occupants
Contact:
Time:
Authority having jurisdiction
Contact:
Time:
Other, if required
Contact:
Time:
9.SYSTEM RESTORED TO NORMAL OPERATION
Date:
Time:

10. CERTIFICATION

10.1 Inspector Certification:

This system, as specified herein, has been inspected and tested according to all NFPA standards cited herein.
Signed:
Printed name:
Date:
Organization:
Title:
Phone:

10.2 Acceptance by Owner or Owner’s Representative:

The undersigned has a service contract for this system in effect as of the date shown below.

Signed:
Printed name:
Date:
Organization:
Title:
Phone:

DEVICE TEST RESULTS

(Attach additional sheets if required)

Device Type
Address
Location
Test Results

NFPA 72, Fig. 14.6.2.4 (p. 1 of 11)

Copyright © 2009 National Fire Protection Association. This form may be copied for individual use other than for resale. It may not be copied for commercial sale or distribution.

File details come from the government source that posted it. Updated .