Life Safety Documentation Requirements

Based on the 2012 edition of the Life Safety Code, for all Healthcare facilities

Revision 4: 12-1-2016

Date Assessment: __________________________

Facility Name: ______________________________________ Location: __________________________________________________

Fire Alarm Test Report
Initiating Devices

Supervisory Signal Devices

Notification Devices

Interface relays and modules

Control panel batteries

Devices/Function
Waterflow switches
Smoke detectors
Heat detectors
Duct detectors
Manual pull stations
Low air pressure switches
Low water level switches
Tamper switches
Strobes
Horns
Bells
Chimes
Magnetic hold-open
Air handler shut-down
Kitchen hood suppression sys
Elevator recall
Magnetic locks / Electric strikes
Fire pump
Smoke dampers
CO2/Clean agent suppression
Sprinkler dry-pipe/pre-action
Overhead rolling fire doors
Charger test
Discharge test
Load voltage test

Smoke detector sensitivity test

Off-premises monitoring transmission equipment

Frequency
Semi-annually
Annually
Annually
Annually
Annually
Quarterly
Quarterly
Semi-annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Semi-annually
2-Years*
Annually

NFPA Standard
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5
72-2010; 14.4.5

Monthly
Annually
Monthly
Semi-annually
Semi-annually
Monthly
Semi-annually
Annually
Semi-annually
Annually

10-2010; 7.2.1.2
10-2010; 7.3.1.1.1
17A-2009; 7.2.1
17A-2009; 7.3.3
12A-2009; 7.1.1
12-2011 4.8.1
12-2011; 4.8.3.5.1
12-2011; 4.8.3.2
2001-2012; 7.1.3
2001-2012; 7.1.1

Fire Suppression System Test Report

Portable fire extinguishers

Alternative suppression
systems

Inspection
Maintenance
Kitchen hood system inspection
Kitchen hood system test
Halon system inspection & test
CO2 system inspection
CO2 system tank weigh
CO2 system test
Clean agent system inspection
Clean agent system test

Date of
Most Recent

Compliant?
Yes
No
N/A

Comment

Fire Suppression (contd)

Devices/Function
Fire pump churn test
Control valve inspection
Pressure Gauge Inspection
Fire department connections
Fire hose valve Inspection
Pre-action/Dry pipe valve priming
water test
Sprinkler inspection
Piping & hanger inspection
Pre-action/Dry pipe valve trip test
Main drain test

Water-based suppression
systems

Control valve exercise

Backflow preventer
Anti-freeze test
Private service fire hydrants
2 inch fire hose valve - test
Fire pump flow test
Occupant use fire hose inspect
1 inch fire hose valve - test
Occupant use fire hose pressure
test
Check valve inspection
Pressure gauge calibration
Standpipe waterflow test
Private fire service mains
Internal inspection of piping
Dry Head sprinkler replacement
QR sprinkler head replacement
SR sprinkler head replacement

Frequency
Monthly
Monthly
Monthly
Quarterly
Quarterly

NFPA Standard
25-2011; 8.3.1
25-2011; 13.3.2.1.1
25-2011; 13.2.7.1
25-2011; 13.7.1
25-2011; 13.5.6.1

Quarterly

25-2011; 13.4.3.2.1

Annually
Annually
Annually
Quarterly*
Annually
Annually
Annually
Annually
Annually
Annually
Annually
Annually
3-Years
5-Years, then
every 3-Years
5-Years
5-Years
5-Years
5-Years
5-Years
10-Years
20-Years
50-Years

25-2011; 5.2.1
25-2011; 5.2.2
25-2011; 13.4.3.2.2
25-2011; 13.2.5.1
25-2011; 13.2.5
25-2011; 13.3.3.1
25-2011; 13.6.2
25-2011; 5.3.4
25-2011; 7.3.2
25-2011; 13.5.6.2.1
25-2011; 8.3.3
1962-2008; 4.3.4
25-2011; 13.5.6.2.2

Weekly
Weekly
20 days to 40
days
Annually*
Annually
3-Years
20 days to 40
days
As per policy
After breach
After breach

110-2010; 8.4.1
110-2010; 8.3.7.1
110-2010; 8.4.2 and
99-2012; 6.4.4.1.1.4
110-2010; 8.4.2.3
110-2010; 8.3.8
110-2010; 8.4.9
110-2010; 8.4.6 and
99-2012; 6.4.4.1.1.4
99-2012; 5.1.14.4.5
99-2012; 5.1.12.1.1
99-2012; 5.1.12.1.1

1962-2008; 4.3.2
25-2011; 13.4.2.1
25-2011; 5.3.2
25-2011; 6.3.1
25-2011; 7.3.1
25-2011; 14.2.1
25-2011; 5.3.1.1.1.6
25-2011; 5.3.1.1.1.3
25-2011; 5.3.1.1.1

Additional Testing & Inspection Requirements

Inspection
Battery electrolyte levels / Voltage
Emergency power generators

Monthly load test

Annual load test (if required)
Annual Fuel Test
3-Year 4-Hour load test

Automatic Transfer Switches

Monthly test with generator

Medical gas and Vacuum sys

Maintenance & testing

Cross-contamination test
Purity and pressure test

Date of
Most Recent

Compliant?
Yes
No
N/A

Comment

Devices/Function
Policy
Alternative Life Safety
Measures

Frequency
Review policy
As needed per
policy

Implementation
Fire Watch

Fire/Smoke damper test

Outside hospital facility
Overhead rolling fire doors
Side-hinged fire doors
Exit signs
Elevator recall
Kitchen hood inspection
Kitchen hood cleaning
Assessment of building
systems for Category desig.

Drop test
Annual test/inspection
Illumination inspection
Test of all elevators equipped with
Fire Fighter Service
Inspect fire suppression system
Remove grease
Risk assessment to determine
Category designation of systems

Date of
Most Recent

Compliant?
Yes
No
N/A

Comment

101-2012; 4.6.10.1

1-Year then 6years

1-Year then 4years
Annually
Annually
Monthly

101-2012; 9.6.1.6 &

25-2011; 15.5.2
80-2010; 19.4 and
105-2010; 6.5.2
80-2010; 19.4 and
105-2010; 6.5.2
80-2010; 5.2.1
101-2012; 7.2.1.15.2
101-2012; 7.10.9.1

Monthly

101-2012; 9.4.6.2

Monthly
Semi-annually

17A-2009; 7.2.1
96- 2011; 11.4

Annually

99-2012; 4.2

Continuous

Inside hospital facility

NFPA Standard
101-2012; 4.6.10.1

*= If Required

Testing & Inspection Time Defined

Weekly, or every 7 days
Monthly or every 30 days
Quarterly or every 3 months
Semi-annually, or every 6 months
Annually or every 12 months
3-Years
5-Years
6-Years

Anytime during a calendar week

Anytime during a calendar month
3 months from the previous test/inspection, conducted during the 3rd month
6 months from the previous test/inspection, conducted during the 6th month
12 months from the previous test/inspection, conducted during the 12th month
36 months from the previous test/inspection, conducted during the 36th month
60 months from the previous test/inspection, conducted during the 60th month
72 months from the previous test/inspection, conducted during the 72nd month

Documentation Should Include the Following:

1. Name of individual performing the activity.
2. Affiliation of the individual performing the activity.
3. The signature of the individual performing the activity.
4. Activity name.

5. Date (month/day/year) that activity was performed.

6. The frequency that is required of the activity.
7. NFPA standard that requires the activity to be performed.
8. The results of the activity, such as Pass or Fail.

New Requirement Due Dates:

New testing and inspection procedures required by the 2012 Life Safety Code are required to have their first test/inspection completed based on the July 5, 2016
effective date. Therefore, the first new test/inspection quarterly requirements are due October 5, 2016; the first new semi-annual test/inspection requirements are due
January 5, 2017; the first new annual test/inspection requirements are due July 5, 2017; the first new 3-year test/inspection requirements are due July 5, 2019; and
the first new 5-year test/inspection requirements are due July 5, 2021.

Copyright 2016 by Keyes Life Safety Compliance, LLC