Fire & Life Safety Survey Intake Form
Business / Facility Name
*
Primary Contact Name
*
Primary Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Contact Email Address
*
example@example.com
Physical Address of Facility
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
What type of occupancy best describes your facility?
*
Please Select
Healthcare / CMS-Regulated (SNF, ALF, ASC, Hospital)
Childcare / Daycare
Church / Place of Worship
Manufacturing / Industrial
Office / Retail / Small Business
Other (please describe)
Approximate square footage of the facility
*
What prompted you to seek a consultation?
*
Please Select
Preparing for a regulatory survey or inspection
Recent inspection finding or violation
New building or recent renovation
Insurance requirement
General compliance check
Specific concern (describe below)
Is there anything specific you'd like us to focus on or a concern you'd like to describe?
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Healthcare/CMS-Regulated Occupancy
What type of healthcare facility is this?
*
Please Select
Skilled Nursing Facility
Assisted Living
Ambulatory Surgery Center
Hospital
Other (please specify)
When was the facility built? If renovated, what year was the most recent renovation?
Is the facility fully sprinklered?
Yes
No
When was the sprinkler system last inspected? By whom?
Is a fire alarm system installed?
Yes
No
If yes; when was the fire alarm system last inspected?
-
Month
-
Day
Year
Date
When was your most recent CMS or state licensing survey?
-
Month
-
Day
Year
Date
Were any Life Safety deficiencies cited at that survey?
Yes
No
If yes; is a Plan of Correction (POC) currently open?
Yes
No
Life Safety deficiency details
Are there any known egress concerns (blocked corridors, doors that do not latch, missing signage)?
Does the facility store or use medical oxygen?
Yes
No
If yes; is it stored in a dedicated room or closet? Describe location and storage details.
Are there any areas of the building currently under construction or renovation?
Yes
No
If yes; construction or renovation details
Childcare/Daycare
How many children are licensed to be in care at one time?
What age groups do you serve?
Infants
Toddlers
Preschool
School-age
Do children nap or sleep at the facility?
Yes
No
If yes - on what floor level does sleeping occur?
How many exits does the facility have?
Are all exit doors operable from the inside without a key or special knowledge?
Yes
No
Is a fire alarm system installed?
Yes
No
Is there a commercial kitchen on site?
Yes
No
When was your most recent DCBS licensing inspection?
-
Month
-
Day
Year
Date
When was your last fire drill; is it documented?
Were any fire or life safety items cited? If yes; please describe the cited fire or life safety items.
Church/Place of Worship
What is the maximum occupant load of your main assembly space?
How was that occupant load determined?
Please Select
Calculated by us
Posted by AHJ
Unknown
Does the facility include any of the following?
Commercial kitchen
Daycare or school
Gymnasium
Basement occupancy
Overnight accommodations
Are aisles in the assembly area maintained clear and at the required width during services?
Yes
No
Is a fire alarm system installed?
Yes
No
If yes; when was it last inspected?
-
Month
-
Day
Year
Date
Is the building sprinklered?
Yes
No
Are exit signs and emergency lighting present and functional?
Yes
No
When was the last time fire extinguishers were inspected?
-
Month
-
Day
Year
Date
Has the building undergone any renovations or changes in use in the last 5 years?
Yes
No
Has the facility ever been inspected by the local fire department or AHJ?
Yes
No
If yes; when and were any items cited?
Manufacturing/Industrial
What type of manufacturing or industrial process occurs at this facility?
Are flammable or combustible liquids stored or used on site?
Yes
No
If yes; approximate quantities.
Are there any spray booths, dip tanks, or similar processes involving flammable materials?
Yes
No
Is there a dust collection system?
Yes
No
If yes; what material is being collected?
Is the facility sprinklered?
Yes
No
If yes; is the system appropriate for the hazard (standard / ESFR / in-rack)?
Standard
ESFR
In-rack
Unknown
Is a fire alarm system installed?
Yes
No
What is the approximate exit access travel distance from the farthest work area to an exit?
Is an Emergency Action Plan (EAP) in place and documented?
Yes
No
When were fire extinguishers last inspected?
-
Month
-
Day
Year
Date
Are the fire extinguishers appropriate for the hazard class?
Yes
No
Has OSHA or the local AHJ conducted an inspection in the last 3 years?
Yes
No
If yes; Were any items cited?
Yes
No
If yes; please describe the items cited.
Office/Retail/Small Business
How many employees or occupants are typically in the building at one time?
Does your business involve any of the following?
Food preparation
Chemical storage
Public assembly
Overnight stays
None of the above
Is a fire alarm system installed?
Yes
No
When were fire extinguishers last inspected?
-
Month
-
Day
Year
Date
Are exit signs and emergency lighting present?
Yes
No
Is the electrical panel accessible and clear of storage?
Yes
No
Are exit doors and pathways kept clear at all times?
Yes
No
Has the space been modified, subdivided, or changed in use since it was originally built or leased?
Yes
No
Has the local fire department or landlord conducted a fire inspection?
Yes
No
If yes, when?
-
Month
-
Day
Year
Date
If yes, were any items cited? Please describe.
What is the primary reason for seeking a consultation today?
"Other" Occupancy Type Description:
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Preferred method of contact?
*
Email
Call
Text Message
What is the best time to reach you?
Morning
Afternoon
Evening
How did you hear about Stevenson Safety Group?
*
Google
Yelp
Social Media
My Employer
Referral
Other
Who referred you?
How did you hear about us?
Is there anything else you'd like us to know before your consultation?
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