Impairment Reporting Impairment Reporting Form "*" indicates required fields Reporting PartyName* First Last Phone*Email* Party Type* Building representative Contractor Other Property InformationBuilding/Business Name Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Impairment CoordinatorThe impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations to mitigate any increased risks have been submitted to management or the property owner or designated representative. (4) Where a fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b) An approved fire watch (c) Establishment of a temporary water supply (d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other AHJs have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (9) All necessary tools and materials have been assembled on the impairment site.Primary Contact Name* First Last Primary Contact Phone*Primary Contact Email* Impairment InformationI am reporting a:* Scheduled Impairment Unscheduled (Emergency) Impairment System(s) Affected* Fire Sprinkler System Fire Alarm and Detection System Special Fire Suppression System Other select all that applyNature of Impairment*Impairment Start Date* MM slash DD slash YYYY Impairment Start Time* Hours : Minutes AM PM AM/PM Estimated End Date* MM slash DD slash YYYY Estimated End Time* Hours : Minutes AM PM AM/PM Mitigation MeasuresFire Watch Implemented?* Yes No Building Occupants Notified?* Yes No Onsite Fire Watch Representative First Last Onsite Fire Watch Representative Phone*Impairment Resolution Procedure* I understandOnce an impairment has been resolved notify the Fire Marshal either by email via [email protected] or by calling the Salisbury Fire Department Administrative Headquarters at (410)548-3120 requesting the Fire Protection Impairment Line, extension 1811, and leaving a message.
