661 Chemawa Road NE - Keizer, Oregon 97303       PHONE: 503-390-9111
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Self Fire Inspection On-line Form

Instructions:  Fill in all the information on the form.  Walk through your business to ensure the safety requirements on the checklist are fulfilled.  If an item is compliant, check the "Yes" box.  If an item is non-compliant, either remedy the problem before submitting this form or check the "No" box and we will follow up in ensuring the hazard is corrected.  If an item does not apply, check the "N/A" box.

Note: Boxes with "*" are required to be checked.

Once you have completed your self-inspection, provide your name, job title & date of inspection and click on the "Submit" button to automatically E-mail your form to the Keizer Fire District.

 
* Business Name:
 
* Street Number:
 
* Street Name:
 
Room/Suite #:
 
* Business Phone Number:
 
E-Mail Address:
 
Emergency Contact Names & Phone Numbers (Provide at least one, in order of calling preference)
(Responsible Parties to be contacted by Dispatch if necessary)
* #1: 
#2: 
#3: 
Address & Premises
* Is your address clearly visible from the street and numbers at least 6 inches in height? [Note: These numbers shall contrast with their background. Numbers shall be a minimum of 6 inches high with a minimum stroke width of 0.5 inch.]
Yes No 
* Are combustible materials and/or vegetation removed from around the building?
Yes No 
Egress (Exiting)
* Are the exitways and doors easily recognizable, unobstructed, maintained functional, and not used as an area for storage?
Yes No 
* If the main exit door is provided with key-locking hardware, is there a sign above the door that states "THIS DOOR TO REMAIN UNLOCKED WHEN BUILDING IS OCCUPIED"?
Yes No N/A 
* Are all other exit doors openable from the inside without the use of a key or any special knowledge or effort?
Yes No N/A 
Electrical
* Are all electrical outlets, switches and junction boxes properly covered with cover plates AND is the electrical system safe from any apparent shock and/or other electrical hazards?
Yes No 
* Are circuit breakers/fuses labeled so as to identify the area protected?
Yes No N/A 
* Are circuit breakers clear of any tape, string, or wire that would affect their operation?
Yes No N/A 
* Is the area maintained clear at least 30 inches in front of electrical panel(s)?
Yes No N/A 
* Are extension cord(s) of heavy construction, maintained in good condition, and only used as temporary wiring, or to service small portable appliances?
Yes No N/A 
* Are extension cord(s) grounded when serving grounded appliances?
Yes No N/A 
* Are extension cord(s) plugged directly into an approved receptacle, power tap or multi-plug adapter and, except for approved multiplug extension cord(s), serve only 1 portable appliance?
Yes No N/A 
* Is the rated capacity of the extension cord(s) equal to or greater than the rated capacity of the portable appliance supplied by the cord AND only long enough to reach the outlet (no excess cord)?
Yes No N/A 
* 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?
Yes No N/A 
Emergency Lighting/Egress Illumination
* If emergency lighting is provided, is it maintained in operable condition?
Yes No N/A 
* Is the means of egress illuminated when the building or structure is occupied?
Yes No N/A 
Exit Signs
* If exit signs are required, are they maintained illuminated or self-luminous?
Yes No N/A 
* Does the backup-battery work? (push the test button, the exit sign should illuminate under battery power)
Yes No N/A 
Fire Extinguishers
* Is there access to a fire extinguisher(s) rated at a minimum 2A-10BC?
Yes No 
* Is the travel distance from all portions of the building less than 75 feet to a fire extinguisher?
Yes No 
* Are all fire extinguisher(s) visible and accessible by employees and the public (not blocked)?
Yes No 
* Have the fire extinguisher(s) been serviced and tagged by a fire extinguisher company within the last 12 months?
Yes No 
* Are the fire extinguisher(s) properly mounted?
[Note: Proper locations-near exit doors where possible, top not exceeding 5 feet high and minimum 4 inches above the floor.
Yes No 
Heat Producing Appliances
* If portable heaters are used, do they turn-off if tipped over? Also, are they plugged directly into wall outlets and kept a minimum of 3 feet away from combustibles?
Yes No N/A 
* Are gas appliances (water heater, furnace, etc.) free of combustible storage? No combustibles are allowed within 3 feet of such devices.
Yes No N/A 
Storage of Combustibles
* Is the storage of combustible materials orderly?
Yes No 
* Are combustible materials not stored beneath the building, structure, or stairs?
Yes No 
* Are the boiler rooms, mechanical rooms and electrical rooms maintained without the storage of any combustible materials within AND is door labeled as to what is behind door?
Yes No N/A 
* Are rubbish containers over 5 1/3 cubic feet (40 gallons) provided with lids and made of noncombustible construction?
Yes No N/A 
* Are dumpsters that are 1.5 cubic yards or more not stored inside buildings and placed more than 5 feet from combustible walls, openings or combustible roof eave lines?
Yes No N/A 
Additional Comments:
 
* Name of Person Responsible for this Report
 
* Title of Person Responsible for this Report
 
* Date of Self-Inspection(format mm/dd/yyyy)
 
 

This list of 30 items on the Self-Fire Inspection Form is intended to cover the most common items/hazards we encounter while performing fire inspections in low hazard occupancies.  It is not intended to be all comprehensive or replace specific code requirements not addressed on the form.  If you have a specific code related question not addressed on this form, please call the Keizer Fire District - Fire Prevention Office at 503-390-9111.

 


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