Area of Refuge Two-Way Communication System Inspection Checklist
Use this form to inspect, test, and document the condition and functionality of an area-of-refuge two-way communication system.
Inspection Details
Inspection Date
*
-
Month
-
Day
Year
Date
Inspection Time
*
Hour Minutes
AM
PM
AM/PM Option
Inspector Name or Identifier
*
Site/Building Name
*
Floor/Area/Location of Area of Refuge
*
System/Equipment Identifier
*
Inspection Type/Frequency
Please Select
Initial
Routine
Monthly
Quarterly
Annual
Post-Repair
Other
System Condition and Component Check
Call Station / Pull Station Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Call Station / Pull Station
1
2
3
4
5
Master Station / Annunciator Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Master Station / Annunciator
6
7
8
9
10
Handset / Speaker Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Handset / Speaker
11
12
13
14
15
Microphone Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Microphone
16
17
18
19
20
Visual Indicators Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Visual Indicators
21
22
23
24
25
Power Supply / Backup Power Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Power Supply / Backup Power
26
27
28
29
30
Wiring / Terminals Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Wiring / Terminals
31
32
33
34
35
Labels / Instructions Status
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Labels / Instructions
36
37
38
39
40
Enclosure / Panel Condition
*
Rows
Present
Operational
Damaged
Missing
Not Tested
Enclosure / Panel
41
42
43
44
45
Overall Component Condition
*
Excellent
Good
Fair
Poor
Unsatisfactory
Functional Test and Observations
Call Initiation Successful
*
Pass
Fail
Not Tested
Voice Clarity
*
1
2
3
4
5
Able to Hear and Be Heard
*
Yes
No
Partially
Not Tested
Response Time
*
Slow
1
2
3
4
5
6
7
8
9
Fast
10
1 is Slow, 10 is Fast
Signal Strength (if applicable)
Weak
1
2
3
4
5
6
7
8
9
Strong
10
1 is Weak, 10 is Strong
Noise or Interference Observed
None
Minor
Moderate
Severe
Alarm or Notification Indicators Operated
*
Pass
Fail
Not Applicable
Failed Test Steps and Deficiency Notes
Corrective Action and Final Assessment
Overall Inspection Result
*
Pass
Fail
Needs Repair
Deficiencies Found
Immediate Corrective Actions Taken
Follow-Up Required
*
Yes
No
Responsible Party / Department
Target Completion Date
-
Month
-
Day
Year
Date
Inspector Confirmation
*
Submit Inspection
Should be Empty: