Portable Fire Extinguisher — Workplace Review
Complete this aid with the employer's responsible person. Use actual site procedures and equipment. Unresolved fields need an owner and follow-up; do not invent an answer or treat this worksheet as authorization to fight a fire.
Employee: ____________________ Employer/site: ____________________
Work area/shift: ____________________ Review date: ____________________
Responsible reviewer and role: ________________________________________
| Workplace detail | Confirmed local instruction |
|---|---|
| My response role: evacuation only or designated equipment user | |
| Limits on my assignment and situations requiring immediate evacuation | |
| Alarm signals and the action each requires | |
| How I raise an alarm from my work area | |
| Actual emergency reporting number/method | |
| Who contacts outside responders | |
| Location details to give when reporting | |
| Primary exit route | |
| Alternate instructions if the route is unsafe | |
| Gathering location | |
| Accountability/check-in procedure and contact | |
| How to report a missing person without reentering | |
| Where the emergency plan is available and who answers questions | |
| Who communicates changes to my duties or the plan |
Equipment and preparation
Record only equipment relevant to your assigned role. A course certificate does not assign a role or demonstrate equipment-use competence.
| Detail | Site-specific record |
|---|---|
| Extinguisher types/models and locations | |
| Hazards and approved uses for these models | |
| Equipment-specific operating instructions reviewed | |
| Additional equipment training required for my assignment | |
| Training actually completed: instructor, date and equipment | |
| Outstanding instruction or practice, responsible person and due date | |
| How to report damaged, discharged, missing or obstructed equipment | |
| Responsible person for equipment inspection and maintenance | |
| Initial/annual education or training arrangements that apply |
Resolve missing information
| Unresolved item | Responsible person | Required action | Resolution/date |
|---|---|---|---|
Employee acknowledgement: ____________________ Date: _______________
Reviewer acknowledgement: ____________________ Date: _______________
Acknowledgements record this discussion only. This is an Evergreen learning aid, not an OSHA-prescribed form, a certification of compliance, proof of practical competence, or a replacement for employer responsibilities. Follow the actual emergency plan and assigned role.