Protective Device Impairment Incident
Entire form must be filled out. An incident number will be assigned after the form is filled out and submitted. Please enter "N/A" into any field which is not applicable.
Caller/Notifier Name:		Policyholder Name:
Caller/Notifier Phone:		Location:
Contact Email:		Fax Phone:

Person Authorizing Shutdown:
Position:
Contact Phone/Cell:

Describe Building(s) Involved in Shutdown:


Type of System being disabled (ie: sprinkler, alarm, etc.)
: Fire Suppression : Security Alarm : Other (describe below)


When will Shutdown Occur (date/time)


How Long Will System Be Shutdown (hrs/days/etc)


Reason for shutdown


Who will repair the system? (Include Repair Start date/time)


Have the proper personnel in the organization been notified		Yes No
NOTE: Alert top management, production management, maintenance personnel and emergency response team that system will be down so they can take necessary safeguards.


Have you notified the Fire Department (Fire System) or Security/Law Enforcement (Alarm System?)		Yes No


Confirmation That Hazardous Operations will be discontinued immediately:		Yes No
(Includes handling and dispensing of flammable liquids and any hot work (cutting or welding, smoking, etc.)) Describe what activity will occur in the effected building(s) during the shutdown period:


Confirmation of Increased Fire Protection in area of Impairment:		Yes No
Example: Establish a fire watch to tour the affected area/building during the entire impairment, obtain additional fire extinguishers, hoses, and other manual firefighting equipment in affected area/building


If the form is completely filled out, then please click the submit button.