Report Of Impaired System Form - Seattle Fire Marshal'S Office
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1REPORT OF IMPAIRED SYSTEM
Seattle Fire Marshal’s Office
rd
nd
220 3
Avenue South, 2
Floor
For planned or emergency impairments to fire protection
Seattle, WA 98104
systems with a duration of more than 8 hours
(206) 386-1450
SFD Administrative Rule 9.04.14
SECTION 1: REPORTING PARTY INFORMATION
SECTION 2: BUILDING INFORMATION
Name of person reporting impairment:
Building name:
____________________________________________________
____________________________________________________
Phone number:
Email:
Building address:
_______________________
________________________
____________________________________________________
Company name:
Building owner or occupant:
____________________________________________________
____________________________________________________
Date:
Time:
Occupant’s phone (if known):
Email address:
_______________________
_________________________
_______________________
_________________________
SECTION 3: IMPAIRED SYSTEM INFORMATION
I am reporting a:
Planned Impairment
Emergency Impairment
System affected and specific location:_______________________________________________________________________________
Nature of impairment: ___________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
Technician: _____________________ Phone: (______)___________________ Email: ______________________________________
Impairment coordinator: ____________________ Phone: (______)___________________ Email: ____________________________
(Property owner or designated agent)
SECTION 4: MITIGATION MEASURES – Complete applicable section below
Planned Impairment
Emergency Impairment (to be completed by Technician)
(to be completed by Impairment Coordinator)
Impairment period start:
Technician name: _______________________________________
Date:_____________________ Time:_____________________
Phone: (_____)_____________ Email:_____________________
Expected to last 8 hours or more?
Impairment period end (estimated):
Yes
No
Date:_____________________ Time:_____________________
Impairment coordinator notified of impairment?
Yes
No
Fire watch scheduled?
Yes
No
Impairment coordinator notified that a fire watch is required by
Building occupants notified?
Yes
No
SFD?
Yes
No
Onsite responsible representative:
Means of notification:
Name: _______________________________________________
Phone
Fax
Email
INSTRUCTIONS FOR NOTIFYING THE SEATTLE FIRE DEPARTMENT OF SYSTEM IMPAIRMENTS
SFD must be notified immediately regarding any emergency impairment that is anticipated to last more than eight hours. SFD must be notified a
minimum of five business days in advance of planned impairments that will last more than eight hours. The notification process has two mandatory
steps:
1.
Email this form to the Seattle Fire Department at SFD_Impairments@seattle.gov.
2.
Call the SFD impairments hotline at (206) 233-7219 and leave a message.
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