REPORT OF IMPAIRED SYSTEM

New Carlisle Fire Dept

REPORT OF IMPAIRED SYSTEM
For planned or emergency impairments to fire protection systems with a duration of more than 4 hours
SECTION 1: REPORTING PARTY INFORMATION
Name of person reporting impairment
Phone number
Please enter a valid telephone numberFormat: (000) 000-0000.
Email*

Confirmation Emailexample@example.com
Company name
Date

MonthDayYear
Time

Hour Minutes

AM/PM Option
SECTION 2: BUILDING INFORMATION
Building name
Building address
Building owner or occupant
Occupant’s phone (if known):
Please enter a valid telephone numberFormat: (000) 000-0000.
Building Occupant Email

Confirmation Emailexample@example.com
SECTION 3: IMPAIRED SYSTEM INFORMATION
Planned ImpairmentEmergency Impairment
System affected and specific location
Nature of Impairment*
Technician*
Technician Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Technician Email

Confirmation Emailexample@example.com
Impairment coordinator*
Property Owner or Designated Agent
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*

Confirmation Emailexample@example.com
SECTION 4: MITIGATION MEASURES – Complete the applicable section below

Planned Impairment (to be completed by Impairment Coordinator)

Emergency Impairment (to be completed by Technician)
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
Impairment period end (estimated)
Date

MonthDayYear
Date
Time

Hour Minutes

AM/PM Option
YesNo
YesNo
Onsite responsible representative:*
Technician name
Phone

Area CodePhone Number
Email
example@example.com
YesNo
YesNo
YesNo
PhoneFaxEmail
INSTRUCTIONS FOR NOTIFYING THE NEW CARLISLE FIRE DEPARTMENT OF SYSTEM IMPAIRMENTS
NCFD must be notified immediately of emergency impairments that are anticipated to last 4+ hours. NCFD must be notified 5 business days in advance of planned impairments that will last 8+ hours. The notification process has two mandatory steps: 1.Complete this form online 2.Submit report of red-tagged system to NCFD using www.thecomplianceengine.com.
Should be Empty:

New Carlisle Fire Dept

SECTION 1: REPORTING PARTY INFORMATION

SECTION 2: BUILDING INFORMATION

SECTION 3: IMPAIRED SYSTEM INFORMATION

Impairment period end (estimated)

INSTRUCTIONS FOR NOTIFYING THE NEW CARLISLE FIRE DEPARTMENT OF SYSTEM IMPAIRMENTS