Self-Fire Inspection Worksheet Template - City Of Jerome Fire Department Page 2
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3Is the ampacity of the extension cord(s) greater than the rated capacity of the portable appliance supplied
by the cord(s)?
If multiple items need to be plugged in, is a power tap utilized with a built-in circuit breaker and is the
power tap plugged directly into a permanently installed receptacle?
Emergency Lighting/Egress Illumination
Yes
No
N/A
If emergency lighting is provided, is it maintained in operable condition?
Is the means of egress illuminated when the building or structure is occupied?
Exit Signs
Yes
No
N/A
If exit signs are required, are they maintained illuminated or self-luminous?
Does the backup-battery work?
(push the test button, the exit sign should illuminate under battery power)
Fire Alarm System
Yes
No
N/A
If the building is equipped with a fire alarm system, has the required annual service of the fire alarm
system been performed by a qualified fire alarm company?
Date of last inspection or annual service: _____/_____/_____
Fire Safety & Evacuation Plans
Yes
No
N/A
If fire drills are required, are they conducted successfully at varying times and under varying conditions
and are records maintained on the premises?
If required, are Evacuation Plans posted?
If required, do you have Fire Safety Plans?
Fire Extinguishers
Yes
No
N/A
Is there unobstructed access to fire extinguisher(s) rated at a minimum 2A-10BC?
Is the travel distance from all portions of the building less than 75’ to a fire extinguisher?
Are all fire extinguishers visible and accessible (not blocked)?
Have the fire extinguisher(s) been serviced/tagged by a fire extinguisher company within the last 12
months? Date Serviced: _____/_____/_____
Are the fire extinguisher(s) properly mounted? (Proper locations-near exit doors where possible, not
exceeding maximum travel distance, properly mounted (maximum 5’ high if <40 lbs., maximum 3 ½’
high if >40 lbs. In all cases, minimum 4” above the ground).
Fire/Smoke Separations
Yes
No
N/A
Are the fire/smoke separations (smoke doors, fire doors, walls, etc.) maintained/working condition?
Fire Suppression Systems
Yes
No
N/A
Is the top of storage maintained a minimum 18” below head deflectors in fire sprinklered areas?
If the building is equipped with a fire sprinkler system, has the required annual service of the
fire sprinkler system been performed in the last year by a qualified sprinkler company?
Date of last inspection or annual service: _____/_____/_____
In commercial cooking applications, has the hood suppression system been serviced in the last
six months and is the hood cleaned at intervals to prevent the accumulation of grease?
Date of last inspection or annual service: _____/_____/_____
Heat Producing Appliances
Yes
No
N/A
If portable electric heaters are used, are they used safely? Also, are they plugged directly into wall outlets
and kept a minimum of 3' away from combustibles? (Open flame unvented heaters are prohibited for use
in a commercial occupancy).
Is the clearance between ignition sources, such as light fixtures, heaters, and flame producing devices,
and combustible storage maintained in an approved manner?
City of Jerome Fire Department
Self Fire Inspection Form Version 01-2015
Page 2 of 3
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