ASSESSMENT NO. : [EENS-FS-     ]{.underline}

**FIRE SAFETY SURVEILLANCE**

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+---+---+---+----+---+-------------------------------------------------------+---+
|   | N |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   | N |   |    |   |                                                       |   |
|   | A |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
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+---+---+---+----+---+-------------------------------------------------------+---+
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|   |   |   |    |   |                                                       |   |
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+---+---+---+----+---+-------------------------------------------------------+---+
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|   |   |   |    | l |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | u |                                                       |   |
|   |   |   |    | c |                                                       |   |
|   |   |   |    | h |                                                       |   |
|   |   |   |    | a |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | w |                                                       |   |
|   |   |   |    | o |                                                       |   |
|   |   |   |    | o |                                                       |   |
|   |   |   |    | d |                                                       |   |
|   |   |   |    | d |                                                       |   |
|   |   |   |    | e |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | k |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | o |                                                       |   |
|   |   |   |    | r |                                                       |   |
|   |   |   |    | c |                                                       |   |
|   |   |   |    | a |                                                       |   |
|   |   |   |    | r |                                                       |   |
|   |   |   |    | d |                                                       |   |
|   |   |   |    | b |                                                       |   |
|   |   |   |    | o |                                                       |   |
|   |   |   |    | a |                                                       |   |
|   |   |   |    | r |                                                       |   |
|   |   |   |    | d |                                                       |   |
|   |   |   |    | b |                                                       |   |
|   |   |   |    | o |                                                       |   |
|   |   |   |    | x |                                                       |   |
|   |   |   |    | e |                                                       |   |
|   |   |   |    | s |                                                       |   |
|   |   |   |    | ? |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   | N |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   | N |   |    |   |                                                       |   |
|   | A |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| C |   |   |    |   |                                                       |   |
| o |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| e |   |   |    |   |                                                       |   |
| n |   |   |    |   |                                                       |   |
| t |   |   |    |   |                                                       |   |
| s |   |   |    |   |                                                       |   |
| : |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| 3 |   | Y |    |   | Are space heaters unplugged when not in use?          |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   |   | N |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   |   | N |    |   |                                                       |   |
|   |   | A |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| C |   |   |    |   |                                                       |   |
| o |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| e |   |   |    |   |                                                       |   |
| n |   |   |    |   |                                                       |   |
| t |   |   |    |   |                                                       |   |
| s |   |   |    |   |                                                       |   |
| : |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| 4 |   |   | Y  |   | Is there any open flame work in laboratories such as  |   |
|   |   |   |    |   | Bunsen burners?                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   |   |   | N  |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
|   |   |   | NA |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| C |   |   |    |   |                                                       |   |
| o |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| m |   |   |    |   |                                                       |   |
| e |   |   |    |   |                                                       |   |
| n |   |   |    |   |                                                       |   |
| t |   |   |    |   |                                                       |   |
| s |   |   |    |   |                                                       |   |
| : |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
|   |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
| * |   |   |    |   |                                                       |   |
+---+---+---+----+---+-------------------------------------------------------+---+

  --------------- ---- ------ ---------------------------------------------------------
  5                    Y      Is open flame work conducted in an engineered safe area,
                              such as a hood for items like Bunsen burners?

                       N      

                       NA     

  **Comments:**               

  **     **                   

  6                    Y      Are all designated smoking areas a minimum of 25 ft away
                              from flammable liquid storage containers, 10 ft away from
                              containers with combustible material (recycling bins,
                              dumpsters) or ground cover (mulch, leaves, wooden
                              floors), and 20 ft away from areas with smoke detection?

                       N      

                       NA     

  **Comments:**               

  **     **                   

  7                    Y      Are "Butt Stop" containers well maintained with no
                              evidence of cigarette butts on the surrounding ground?

                       N      

                       NA     

  **Comments:**               

  **     **                   

  **Fire                      
  Protection**                

  8               Y           Are any Fire Doors propped open?

                  N           

                  NA          

  **Comments:**               

  **     **                   

  9                    Y      Are self-closing fire doors kept clear so that they can
                              close if needed?

                       N      

                       NA     

  **Comments:**               

  **     **                   
  --------------- ---- ------ ---------------------------------------------------------

  --------------- ---- ---- ---- -------------- ---------------------------------------------------------
  10                        Y                   Are all exit paths kept clear and clearly marked exit?

                            N                   

                            NA                  

  **Comments:**                                 

  **     **                                     

  11                   Y                        For flammable or combustible liquids, is there more than
                                                1-days supply stored outside of an approved storage
                                                cabinet?

                       N                        

                       NA                       

  **Comments:**                                 

  **     **                                     

  12              Y              Are there more 
                                 than three     
                                 flammable      
                                 storage        
                                 cabinets       
                                 within 100     
                                 feet of each   
                                 other? (May    
                                 require a fire 
                                 evaluation for 
                                 size of fire   
                                 area, contact  
                                 fire safety    
                                 SME)           

                  N                             

                  NA                            

  **Comments:**                                 

  **     **                                     

  13              Y              Are any        
                                 flammables or  
                                 combustibles   
                                 stored in exit 
                                 enclosures     
                                 such as        
                                 stairwells? If 
                                 so, relocation 
                                 is required.   

                  N                             

                  NA                            

  **Comments:**                                 

  **     **                                     
  --------------- ---- ---- ---- -------------- ---------------------------------------------------------

  --------------- ------ ------------------------------------------------------------
  14              Y      Does the facility Firehouse Response Card acknowledge that
                         there is flammable storage and where it is? (Access from the
                         emergency services home page)

                  N      

                  NA     

  **Comments:**          

  **     **              

  15              Y      Is there a fire extinguisher between 10 and 25 feet from the
                         cabinet or room where flammable or combustible liquids are
                         stored?

                  N      

                  NA     

  **Comments:**          

  **     **              
  --------------- ------ ------------------------------------------------------------

> Comments: Identify comments against question number noted above

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> Improvement Opportunities:  

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> Lessons Learned:  

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Assessor [     \_]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Assessor Signature[               ]{.underline}
>
> Title [     ]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Date [     ]{.underline}\_\_\_\_\_\_\_
>
> Reviewed by: Manager, Research operations Office
> [               ]{.underline}
>
> Date [          ]{.underline}
>
> Lab-Wide Implications? No Yes (Submit Lessons Learned to SBMS)