Form No.
___
_________
District _ _____
Date ___
_____
_______
SAFETY AUDIT FORM
Rescue
1122
Premises Information
Premises
Name
Address
Building
Area / Age:
Premises
type:
Occupancy
type:
Owners Name/ Focal Person: ___ ______________________
Contact No. ______________
Plot size: ______________ (Marla / Kanal/Sq.ft) Total covered Area
_____ Sq.ft
Height of Building ____ ft
Age of the building ___ _____ Month / Years
Industrial
Commercial
Government
Residential
Home Apartments/Flats Hotel / Boarding Warehouse
Industry/Factory
Hospital Office /Shop School /College/university Plaza
Restaurant
Cinema/ auditorium
Banquet hall Bus Terminal Railway Station Airport Other
_________
Government Semi Govt.
Owner ship
Constructio
n type:
Building
Design
Leased
Rented
Private
Owned
Other ______________
Other ______________
Fully Framed Semi Framed Steel Framed Wooden Framed
Brick Masonry
Single Storey
Multiple Storey
Basement Yes No
No. of Floors (Above ground Level) ______
No. of Basements _________
Total No. of Floors ________
Occupancy & Storage
No. of
Occupants
Interiors
Storage
Type:
Staff ______ Residents ______ Visitors ____ Others ____________Total= ________
paint Plastic Wood working Partition False ceiling Wallpaper
Carpets
curtains/blinds Glass Other _______
Electrical Appliances Wood
Petroleum Products Paints
Fabrics
Hazardous material Medicines
Paper & board
Metals
Non metals
Explosive
Fertilizer
Leather
Chemical
Other
_________
Quantity Of Material:
Low Quantity
Medium Quantity
Bulk Quantity
{{{
Punjab Emergency Service, Rescue 1122
Page 1 of 3
SAFETY AUDIT FORM
Rescue
1122
Loose Electrical wiring
Yes No
General
Safety
Arrangem
ents
Over loaded socket /
plug
Yes No
Type of wiring
Gas supply Main cutOpen
Underground off valve
Both
Yes No
Alternate power
Circuit breaker for each
supply system Yes
portion Yes No
No
Damaged / tapped
wires Yes No
Electrical Main cutoff switch Yes
No
Building properly
earthed Yes No
Ducting Material
Used
Emergency lighting
Flammable
Yes No
Nonflammable
N/A
Designated smoking
Central air conditioning No Smoking is followed
area
system Yes No
Yes No
Yes No
Proper house keeping
First Aid box
Separate parking
Yes No
Yes No
Yes No
System manned at all
Building insured
times
Other _____
__
Yes No
Yes No
Proper ventilation
ducts
Yes No
Clear Vehicle Access to the Building
Yes No
Access Road__________
Emergenc
y
Arrangeme
nts
Width of
No. of Emergency Exits
_____
Functional ____________ Locked __
____________
Obstruction free __ __ ________ Clearly marked ____ ____ Illuminated __ ___
______
No. Emergency Staircases _ ___
External Staircase Internal
Staircase
Near Exit Illuminated
Obstruction Free
Fire Doors
Yes No
No. of Fire Doors
__ ____
__
Emergency Signs
Illuminated
Yes No
Clearly Displayed
Emergency Evacuation Plan Yes No
Clearly Displayed
Building Layout
Fire Plan Emergency Exits Marked Assembly
Area Marked
Fire
Detection
Systems
Fire Detection & Alarm System
Yes No
Functional
Non-functional
Type:
Automatic
Control Panel:
Yes No
points ___ _______
Manual
No. of manual call
Punjab Emergency Service, Rescue 1122
Page 2 of 3
SAFETY AUDIT FORM
No. of Smoke Detector ___ __ ___
Rescue
1122
Functional __ ______ Non-
Functional __ _______
No. of
Heat Detectors _________ Functional ____ _____ Non-Functional
__ ________
Punjab Emergency Service, Rescue 1122
Page 3 of 3
SAFETY AUDIT FORM
Rescue
1122
No. of Portable Fire Extinguishers __ ____ Functional __ ___ NonFunctional _______
Fire Extinguisher Types
D.C.P CO2
Water
Other _ ______
Sprinkler System Yes No
Status:
Wet System Dry
System
Functional
Non-Functional
No. of water Sprinklers
Functional _ ___
Non-Functional ______
No. of Fire Hose Cabinet __ ____ ___
Functional _
___
Non-
Functional _______
Fire Hydrant System
Yes No
No. of Fire
Hydrants ___ _________
Status: Functional Non-Functional Pressure
Maintained (3-5 Bar)
Fire Hydrant Types
Dry Riser Wet Riser
Electric Fire
Pump
Independent Overhead water tank Capacity _
__
Fire Safety
__
Arrangeme
Underground water tank
Capacity
nts
_________
_
No. of Fire Hose Reels __ __ ___ Functional _
_____ NonFunctional __ _______
Fire Suppression System
Yes No
TYPE_ NIL_______
Functional Non-Functional
Firefighting Trainings
Yes No
No. of Trained
Staff:____ _________
Type of Training _______________________________
Safe working practices followed Yes No
Regular Evacuation Drills
Yes No
Record
Maintained Yes No
Regular inspection of Firefighting Equipment Yes No
Maintained Yes No
Availability of local fire service/Team Yes No
Nearest Fire Station/Team __________________________________ Distance:
__________
Nearest Lorry Filling Point _____________________
_______
Distance:
_____
_
Any other information / observation:
Conclusion:
Low risk level
Medium risk level
High risk level
Punjab Emergency Service, Rescue 1122
Page 4 of 3
SAFETY AUDIT FORM
(No major additional control required, there may be
(Considerable resources may have to be
a need for consideration of improvement that
allocated to reduce the risk. If the building is
involved minor cost.)
unoccupied, it should not be occupied until the
risk has been reduced. If occupied, urgent action
should be taken
Prepared By:
Signature:________________
___
Name:_____________________
_
Date:______________________
_
Rescue
1122
(The building must not be occupied
until the risk
is reduced)
Verified By:
Signature:________________
___
Name:_____________________
_
Date:______________________
_
Punjab Emergency Service, Rescue 1122
Page 5 of 3
