Impairment Worksheet

Todays Date:

Person completing form:

(Date format: m/d/yyyy)

Contact number (enter area code): () -

Company/Affiliation:

General Building Information

Building address:
Building name:
Building number:

Facility manager:

Office & Cell:

Email address:

Impairment Information
Type of system impaired:
Reason for impairment:
Extent of impairment:

Date and time of impairment to begin:

Date and time of impairment completed:

Person(s) and affiliation conducting work:

Contact phone number of person(s) conducting work (enter area code):

Pre-Impairment Notification Reminder

1. EHS IC contacted

() -

Restoration of Impaired System

1. Impaired system has been restored and

tested operational

2. Facility manager contacted

2. Verify all impairment tags removed

3. UWPD dispatch contacted

3. Fire watch forms sent to EHS IC

4. Fire watch needed

4. Impairment forms sent to EHS IC

5. Building evacuated

5. EHS IC contacted

6. Impairment tags been placed

6. Facility manager contacted

7. UWPD dispatched contacted
Important Contacts - Provide Email Notification to the Following
EHS Impairment Coordinator, Jeff Schiller:
UWPD dispatch:
UW-Madison, FP&M (CARS):
Madison Fire Department:
Facility manager of impaired building
Emergency:

608-225-7693
608-264-2677
608-263-3333

jschiller@fpm.wisc.edu
uwpddispatch@mhub.uwpd.wisc.edu
physical.plant.cars@fpm.wisc.edu
fireprevention@cityofmadison.com

911

Reference
NFPA 72 (Chapter 4)

NFPA 25 (Chapter 14)

IFC (Chapter 9)