Enclosure Integrity Test-Check List Form

Building: ___________________________
Contact: ________________________
Phone: ___________________________
Room Name:_____________________________________________________________

Pretest Checklist

____
Compete prior to scheduling the test. Refer to guide for further information on issue
raised below.
Date of Pre-Inspection: _______________________ By: ______________________________
Ste
p

Is there a suspended ceiling?

_______________________________________________________
If the walls go slab-to-slab and have been very well sealed or the room is very
large?

1a

Are all suspended ceiling tiles in place?

______________________________________________

Dampers installed on all external HVAC ducts?

_________________________________________
Can they be shut for the door fan test?
______________________________________________

Dampers installed on fresh air inlet ducts?

____________________________________________
Can they be shut for the door fan test?
_______________________________________________

All apparent leaks must be sealed and hardware item installed?

___________________________

Doorway sizes?

Five Minute HVAC shut down can be arranged? _____ With who:
_________________________

Small room problem

Height __________, Width_____________

For Agnice Notes: (e.g. Non-standard equipment needed for test such as extra
blowers or tape and poly)

Deficiencies still to be fixed:

Doors, door hardware, door weather-stripping/sweeps/door bottom, glass, dampers,

floor/wall joint, room wall & floor penetrations, open conduit ends, floor drain
primed, above ceiling leaks, roof/will leaks, other:
Proposed Test Date: _______ 20__
Technician:_____________________ Witnessing
Authority:_________________________________
Step

Elevation (Within 600 ft or 200m):

Input into the Building/Room tab on
CA2001

Ft I m
10

Sketch plan view showing dimensions below and calculate floor area, heights
and volume. Sketch side view of height. Show door open, closed and mark
where Door fan will be mounted

10a

Net protected room

volume

= Floor Area ________X Maximum protected height _______ = ________

_____

10b
11

Room operating temperature

___ F I C
Maximum Protected =Above ceiling (O if not protected _____+Room ___ + Sub-floor ____ =
_____ ft I m
height

12

Minimum agent retention time (Normally10 minutes)

13

Agent
Descripti
on

Agent____________________
Actual quantity determined from tags______,
weighting___ or_________

____min
Lb l kg