Fire Protection UW Impairment Form

Will the impairment take place in the next 48 hours?

Yes
No

Please return within 48 of the impairment begin date and time. EH&S Fire & Life is no longer accepting Pre-Impairment forms before this time frame.

Impairment Questions:

Today's Date:*

Name of Person Completing Form:*

First Last

Email Address of Person Completing Form:*

Phone Number of Person Completing Form:*

Company/Affiliation:*

Project Name*

Project Number*

The information filled in on this form will be sent to you. Please select the 'yes' button to add the facility manager's email and up to 4 additional email addresses. The facility manager is a required email field.*

Yes
No

Facility Manager's Email

Additional Email #2

Additional Email #3

Additional Email #4

Additional Email #5

Search for a Building*

Impairment Information

Type of Fire Protection System being Impaired:*

Area(s) to be Impaired:*

Reason for Fire Protection System Impairment:*

Asbestos Abatement
Inspection/Testing
Maintenance
Repair
Emergency
Other

Other Explain

Date of Impairment to Begin*

Time of Impairment to Begin:*

:

Estimated length of time for impairment:*

Person(s) and affiliation conducting work:*

Contact phone number of person(s) conducting work:*

Pre-Impairment Notification Reminder

Facility manager contacted?*

Yes
No

You must call the UWPD dispatch at 608-264-2677 prior to impairing the fire protection system.*

Yes
No

Fire watch needed?*

Yes
No

Link to Impairment Fire Watch Form: https://ehs.wisc.edu/fire-life-safety/fire-protection-uw-impairment-fire-watch-form/

Building evacuated?*

Yes
No

Impairment tags been placed?*

Yes
No

STOP!

SELECT "PRE-IMPAIRMENT SUBMIT" LOCATED AT THE BOTTOM OF THE PAGE TO SUBMIT THE PRE-IMPAIRMENT FORM. THE FOLLOWING WILL BE NOTIFIED BY SELECTING SUBMIT:

CITY OF MADISON FIRE DEPARTMENT
UW - MADISON POLICE DEPARTMENT
ENVIRONMENTAL HEALTH & SAFETY
PHYSICAL PLANT CUSTOMER SERVICE (CARS)
JEFF SCHILLER - FIRE & LIFE SAFETY
MITCHELL SUTTER - FIRE & LIFE SAFETY

YOU MUST CONTACT UW PHYSICAL PLANT TO SCHEDULE AN ELECTRICIAN (608-263-3333) OR PLUMBER (608-262-9633).

Restoration of Impaired System

Is the system back in service?*

Yes

Impairment Completion Questions

Date of Impairment Completed:*

Time of Impairment Completed:*

:

Impaired system has been restored and tested operational?*

Yes
No

Verified all impairment tags removed?*

Yes
No

Fire watch forms sent to EHS IC?*

Yes
No

Facility manager contacted?*

Yes
No

You must call the UWPD dispatch at 608-264-2677 when the fire protection system is back in service.*

Yes
No

Name

This field is for validation purposes and should be left unchanged.