SlideShare a Scribd company logo
1 of 3
DATE
COMPANY LOGO
FIRE SAFETY MAINTENANCE REPORT YYYY
ESTABLISHMENT : Building Name
OWNER : Company Name
LOCATION : Address
BUILDING DESCRIPTION AND BACKGROUND:
Short Description
FIRE PROTECTION AND LIFE SAFETY ISSUES OF THE BUILDING AND
MAINTENANCE:
1. Exit and Egress
a. Exits:
Short Description
b. Egress:
Short Description
2. Fire Suppression
Short Description
Fire Suppression
Equipment
Condition Preventive Maintenance Frequency /
Action Taken / Remarks
Fire Pump
Fire Pump Control
Panel
Jockey Pump
Jockey Pump
Control Panel
Sprinkler Heads
Fire Hose
Cabinets and Fire
Hoses
Whole Sprinkler
System
Others:
Siamese Twins
Fire Extinguisher
DATE
3. Fire Detection, Alarm Communication, and Evaluation System
Short Description
Fire Detection
and Alarm
Equipment
Condition Preventive Maintenance Frequency /
Action Taken / Remarks
Fire Alarm Control
Panel
Smoke Detectors
Heat Detectors
Manual Call Point
Alarm Bells
4. Emergency Power Supply
Short description
Emergency
Power Supply
Equipment
Condition Preventive Maintenance Frequency /
Action Taken / Remarks
Emergency Lights
Back-up
Generators
OVERALL COMMENTS AND REMARKS:
• Deficiencies/Remarks/Conclusions
REPORTED BY: __Name and Signature____
Company Name / Position
DATE
Attachments:
1. Photo of the building
2. Photo of the fire pump and jockey pump (if you have fire pump and jockey pump)
3. Photo of the Emergency Exit Stair
4. Photo of the Emergency Exit Door (1 from inside and 1 from outside)
5. Photo of the Siamese Twin
6. Photos of the Fire Sprinklers
7. Photos of the Fire extinguishers
8. Photos of the Emergency Lights
9. Photos of the Exits and Emergency Signages
10.Photocopy of Maintenance reports for all equipment (if you have or required)

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FSMR - FIRE SAFETY MAINTENANCE REPORT FORM.pdf

  • 1. DATE COMPANY LOGO FIRE SAFETY MAINTENANCE REPORT YYYY ESTABLISHMENT : Building Name OWNER : Company Name LOCATION : Address BUILDING DESCRIPTION AND BACKGROUND: Short Description FIRE PROTECTION AND LIFE SAFETY ISSUES OF THE BUILDING AND MAINTENANCE: 1. Exit and Egress a. Exits: Short Description b. Egress: Short Description 2. Fire Suppression Short Description Fire Suppression Equipment Condition Preventive Maintenance Frequency / Action Taken / Remarks Fire Pump Fire Pump Control Panel Jockey Pump Jockey Pump Control Panel Sprinkler Heads Fire Hose Cabinets and Fire Hoses Whole Sprinkler System Others: Siamese Twins Fire Extinguisher
  • 2. DATE 3. Fire Detection, Alarm Communication, and Evaluation System Short Description Fire Detection and Alarm Equipment Condition Preventive Maintenance Frequency / Action Taken / Remarks Fire Alarm Control Panel Smoke Detectors Heat Detectors Manual Call Point Alarm Bells 4. Emergency Power Supply Short description Emergency Power Supply Equipment Condition Preventive Maintenance Frequency / Action Taken / Remarks Emergency Lights Back-up Generators OVERALL COMMENTS AND REMARKS: • Deficiencies/Remarks/Conclusions REPORTED BY: __Name and Signature____ Company Name / Position
  • 3. DATE Attachments: 1. Photo of the building 2. Photo of the fire pump and jockey pump (if you have fire pump and jockey pump) 3. Photo of the Emergency Exit Stair 4. Photo of the Emergency Exit Door (1 from inside and 1 from outside) 5. Photo of the Siamese Twin 6. Photos of the Fire Sprinklers 7. Photos of the Fire extinguishers 8. Photos of the Emergency Lights 9. Photos of the Exits and Emergency Signages 10.Photocopy of Maintenance reports for all equipment (if you have or required)