Passive Fire Barrier Inspection Survey
Use this form to record a passive fire barrier inspection, document defects or compliance status, attach evidence, and note corrective actions.
Inspection Details
Inspector Name
*
First Name
Last Name
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Company / Organization
*
Site / Building Name
*
Exact Inspected Location / Zone
*
Barrier Identification and Survey Scope
Passive fire barrier type
*
Firestop sealant
Fire-rated wall penetration
Fire-rated floor penetration
Fire door/frame interface
Fire damper interface
Other
Barrier location description
*
Area inspected / room / floor / grid reference
*
Inspection method
*
Visual only
Visual plus access panel
Visual plus photo review
Other
Condition Assessment
Overall Condition
*
1
2
3
4
5
Compliance Status
*
Please Select
Compliant
Minor Deficiency
Major Deficiency
Inaccessible
Not Inspected
Defect Check
*
Rows
Present
Absent
Not Applicable
Comments
Cracks
1
2
3
Gaps
4
5
6
Missing Sealant
7
8
9
Damaged Insulation
10
11
12
Unsealed Penetrations
13
14
15
Labeling Issues
16
17
18
Deterioration
19
20
21
Obstruction
22
23
24
Overall Condition Notes
Evidence and Findings
Inspection Evidence Photos/Files
*
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Defect Description
*
Exact Defect Location Within Barrier System
*
Severity / Priority
*
Low
Medium
High
Critical
Immediate Risk Note or Temporary Measures
Corrective Actions and Outcome
Recommended Corrective Action
*
Responsible Party / Owner
*
Target Completion Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reinspection Required?
*
Yes
No
Final Outcome / Status
*
Please Select
Pass
Pass with Observations
Fail
Needs Follow-up
Submit Inspection
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