Life Safety Compliance Registration
1.

LSE Client Number
 

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2.

Please enter the information indicated below.

By entering my personal information, I consent to receive email communications from the survey author's organization based on the information collected.

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com

3.

Barrier Number?
 

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4.

Is the barrier properly highlighted on your Life Safety Drawings?
YES
NO
I DO NOT KNOW
  • Comment:

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5.

Barrier (Wall or Floor) Rating?
Smoke Seal
30 MInutes
1 Hour
2 Hour
3 Hour
4 Hour
Infectious Disease
Radiological Protection
Hazardous Materials
Special Protection
Other  
6.

Is the barrier stenciled properly with the rating and "Do Not Penetrate"?
YES
NO
UNKNOWN
7.

Type of Construction
Drywall/Sheetrock/Gyp-
sum
Block
Concrete
Brick
Lead Panel
Laminate
Special Construction
Other  
8.

Is the wall joint at the ceiling and floor line filled with firestop material?
Yes
No
Not Known
9.

Are there items penetrating the wall?
Yes
No
Unknown
10.

What type(s) of Life Safety Devices are present in this barrier?
 YES NO NOT SURE   
Fire Door   
Duct Work   
Pipes, Cables and Wires   
Tubes and Transports   
Structural Members   
Access Door Above Ceiling   
Other   
  • Comment:

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11.

 Door Barcode Number
 

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12.

Damper Barcode Number
 

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13.

Penetration Barcode Number
 

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14.

What is the overall condition of the rated barrier system (damper, stops and doors)?
Acceptable
Needs Work
No Documentation - Unknown
Not Accessible
Under Construction
Unacceptable
  • Comment:

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15.

What actions were taken today?
Barcodes, Placard or Stenciling
Inventory and Data Collection
Inspection of Finished Work
Installation of Life Safety System (damper/stop/door)
General Assessment
Joint Commission or CARF Inspection
Repair and Maintenance
Generate Repair Work Order
Completed Work Order
Work in Progress
Installed Placard
Installed Stencil
Installed Barcode
Nothing
Other  
  • Comment:

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