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Floor Warden Questionnaire
IIPP/EAP Questionnaire
Floor Warden Questionnaire
Thank you for taking the time to enhance your internal operations. The following questionnaire is designed to assist ICE Safety Solutions in collecting information to build your Floor Warden training.
Step 1 of 4
25%
General Company Information
Company Name
*
Address of Building
*
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Primary Contact
Name
*
First
Last
Email
*
Direct Phone
*
Mobile Phone
Is the building/facility leased or owned?
*
Leased
Owned
Is the building/facility free standing?
*
Yes
No
List Your Occupied Floors
*
e.g. 4, 7, 8, 9.
Select All Life Safety Features of Your Building
*
Select All
Alarm - Audible
Alarm - Visual Strobe
Automated Closing Doors (Fire Doors)
Emergency Stairwells (Fire Rated)
Exterior Breakout Windows (for Fire Department)
Fire Extinguishers
Fire Sprinklers
Illuminated Exit Signs
What is the procedure to call Emergency Responders for a Medical Emergency at the worksite?
*
Please note any special steps needed to dial out from company telephones.
Evacuation
Please Upload Image(s) of Assembly Areas
*
Assembly areas are the locations where you'd gather after evacuating the building. We recommend taking a screenshot from google maps and making notes on the image with your 'paint' program. You can also upload street level photos that help, such as a photo of a particular light post/street sign.
Drop files here or
Accepted file types: jpg, gif, pdf, png.
Upload Floor Plans
*
Please ensure there is an image available for each floor your company occupies in the building.
Drop files here or
Please list hazardous chemicals or substances.
Do the chemicals have Safety Data Sheets (SDS) easily accessible to employees?
Yes
No
Please describe the location of the Safety Data Sheets.
What method can Employees retain the SDS on their Smart Phones. What Smart Phone Apps are you using?
Safety Supplies
Check all types of safety supplies/equipment that are available.
*
First Aid Kits
AEDs
Disaster Supplies
Eyewash Stations
Personal Protective Equipment
Fire Extinguishers
Other
Other Safety Equipment
Please select all types of disaster supplies available.
Food (72 hours)
Water (72 hours)
Flashlights
Helmets
Gloves
Vests
Safety Glasses
Evacuation Devices (e.g. Stair Chair)
List locations of disaster supplies.
Example: Copy Room, 2nd Floor
Please attach a copy of your most recent Injury and Illness Prevention Plan (IIPP) or Emergency Action Plan (EAP).
Accepted file types: pdf, doc, docx.
That's it! We'll get started on this. In the meantime, do you need someone to contact you about any of these?
CPR/First Aid/AED Training
ERT/Floor Warden Training
Bomb Threat, Fire Extinguisher, or Other Safety Training
Online OSHA Training
Safety Supplies
First Aid Kit/AED Inspections and Maintenance
AED Program Management
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