Supplemental Information Print this PDF

Name: Fire Safety Policy
Responsible Office: Office of Emergency Operations

Applies to: (examples; Faculty,Staff, Students, etc)

Faculty , Staff , Students , Contractors_Vendors

Policy Overview:

Issued: 01-01-2017
Next Review Date: 02-04-2023
Frequency of Reviews: Biennially

The purpose of this safety policy and procedure is to establish the methods and accountability for fire protection and safety at University of Health Sciences and Pharmacy in St. Louis. 




Class A Fires

Fires that involve ordinary combustible solids or “surface burning fires.”  Examples of Class A fires include wood, clothing, plastics, paper, and asphalt.

Class B Fires

Fires that involve gases, greases, and flammable combustible liquids.  Examples of Class B fires include gasoline, kerosene, alcohol, and lubricating oils and greases.

Class C Fires

Fires that involve electrical circuits of electrical equipment or fires near such equipment. Examples of Class C fires include electrical motors, switch boxes, junction boxes, transformers, and energized or live wires.

Class D Fires

Fires that involve combustible metals which require special fire tactics and extinguishing agents.  Class D Fires include metals such as magnesium, potassium, powdered aluminum, zinc, sodium, and titanium.

Class K Fires


Class K Fires are technically a subclass of class B flames, since it involves flammable liquid.  However, because of some unique characteristics related to this type of fire, it was designated separately and requires a distinct battling method.  Class K fires burn a specific type of fuel, namely cooking fat and oils, and can spread quickly, causing damage and potential injury.

Fixed Extinguishing System

A permanently installed system that either extinguishes or controls a fire within the area.


A colorless electrically nonconductive gas that is a medium for extinguishing fires by inhibiting the chemical chain reaction of fuel and oxygen.

Hydrostatic Testing

Testing performed on fire extinguisher cylinders to check the integrity of the cylinders.

Sterno (Solid Fuel)

Cans of denatured and jellied alcohol fuel used for the purposes of warming food.

Incipient Fires

Fires which are in the initial or beginning stage and which can be controlled or extinguished by portable fire extinguishers, standpipe, or small hose system without the need for protective clothing or breathing apparatus.


A visual check of fire protection systems and equipment to ensure that they are in place, charged, and ready for use in the event of fire.

Sprinkler System

A fire protection system with overhead discharge nozzles installed in a systematic pattern that ejects an extinguishing medium from ceiling to floor level.

Fire Alarm Pull Station

An active fire protection device, usually wall-mounted, that when activated, initiates an alarm on a fire alarm system.


I. Scope and Applicability

a.      Fire protection is important to UHSP to minimize loss of life and property. The cost of fire protection is small compared to potential costs of incalculable human suffering and lost property.

b.      This safety policy and procedure provides guidelines for implementing fire protection in the workplace. It includes provisions for training, discussion on portable fire extinguisher’s classification and use, and information on fire hoses, water sprinkler systems, kitchen systems, and sprinkler system’s alarms.

c.      This document also details the areas of responsibility for faculty, lab managers, supervisors, and employees within UHSP. This safety policy and procedure applies to all personnel.

II. Reference

a.      The safety policy and procedure is established in accordance with Occupational Safety and Health Standards for General Industry (29 CFR 1910.157), NFPA 10 and NFPA 96.


I. Policy
a.    It is the policy of UHSP to provide a place of employment that is free from recognized hazards that cause or are likely to cause death or serious physical harm to employees, students or the public. Therefore, all UHSP facilities will have fire protection equipment to minimize the results from fire hazards. When fire hazards exist that cannot be eliminated, then engineering practices, administrative practices, safe work practices, and proper training regarding Fire Protection will be implemented. These measures will be implemented to minimize those hazards to ensure the safety of students, employees and the public.

II. General Responsibilities
a.    It is the responsibility of each manager/unit head, supervisor, and employee to ensure implementation of UHSP's policy on Fire Protection. It is also the responsibility of each UHSP student and employee to immediately report any unsafe act or condition to his or her supervisor and to become familiar with the use and location of fire-fighting equipment, fire systems and evacuation procedures.

III.    General Provisions
a.    This section details the provisions of this safety policy and procedure with each provision discussed in a separate subsection. The provisions adopted by UHSP are:
    i.    Drills, Training, Education
    ii.    Portable Fire Extinguishers
    iii.    Fire Hoses
    iv.    Water Extinguishing Sprinkler Systems
    v.    Smoke Detectors
    vi.    Kitchen Extinguishing Systems
    vii.    Fire Alarms and Alarms for Sprinkler Systems
    viii.    Open Flames
    ix.    Holiday and Other Decorations
    x.    Electrical Wiring and Appliances

IV.    Training    
a.    Employees will be offered training on the general principles of fire protection, procedures and evacuation upon initial employment and annually thereafter. Training will consist of:
    i.    Classification, Ratings, and Performance of Fire Extinguishers
    ii.    Classification of Hazards
    iii.    Evacuation Procedures, to Include Location of Fire Exits and Escape     Routes
    iv.    Use of Fire Extinguishers
    v.    Purpose and Basic Operations of Alarm Systems
b.    Additionally, supervisors or designated employees will be trained in:
    i.    Selection and Distribution of Extinguishers
    ii.    Inspection, Maintenance, and Proper Charging of Extinguishers

V.    Portable Fire Extinguishers
a.    UHSP shall provide portable fire extinguishers that are:
    i.    Consistent with the hazard
    ii.    Properly mounted and located
    iii.    Inspected, maintained, and tested
b.    Portable fire extinguishers will be selected and distributed based on the classes of anticipated fires, and the size and degree of hazard. Most fires in UHSP operations will include materials found in Classes A, B, and C. Thus, the most common type of extinguisher UHSP will provide will be designed to effectively suppress these particular conditions. However, fire extinguishers or extinguishing agent for Class D fires will be provided when hazards associated with Class D fires exist (e.g. sodium metal in the chemistry lab).  Halon or CO2 fires extinguishers will be provided to extinguish Class C fires involving computers and related equipment.
c.    Portable fire extinguishers will be mounted conspicuously, located and identified so they are readily accessible. Extinguisher locations will be carefully selected to ensure extinguishers are adequately spaced and are not in danger of being damaged by vehicles, weather, or storage materials.
d.    Employees will be informed of the location of fire extinguishers.  Extinguishers will be visible from a distance of at least 3 feet. Wall markings for fire extinguisher locations will be visible from a distance of at least 25 feet.  They shall be located along normal paths of travel, including exits from an area. All paths to fire extinguishers must remain clear to provide easy access.
e.    Portable fire extinguishers shall be visually inspected monthly to ensure they are charged and operable. They are to be recharged after use or if there is evidence of pressure leakage. Fire extinguishers will be equipped with an inspection tag that will be exchanged annually by a selected contract vendor. Additionally, tags will be replaced when they are lost or removed.
f.    Any extinguisher that shows excessive wear, damage or unserviceable condition will be removed from service and replaced by an operable extinguisher. Fire extinguisher maintenance will be performed at least annually by an approved contractor or trained UHSP personnel.
g.    During any period when an extinguisher is removed from service for testing, another extinguisher must replace the extinguisher out for testing.  Annual inspection records will be maintained for review by regulatory agencies and for internal audit purposes.  Appendix A presents the portable fire extinguisher location, annual inspection date, hydrostatic testing schedule for UHSP.

VI.    Water-Based Sprinkler Systems
a.    Water extinguishing systems are fixed extinguishing systems used in areas requiring a higher degree of fire protection than is provided by fire extinguishers. These are heat-activated systems with automatic water supplies and overhead ceiling mounted sprinklers. Upon being activated, these water- extinguishing systems discharge water over the fire area. Water extinguishing systems, to include the fire pumps, will be inspected quarterly by an approved outside contractor to ensure their operation is sufficient.

VII.    Smoke Detectors
a.    All UHSP buildings are equipped with smoke detectors. In several of the buildings, the activation of the sprinkler system is dependent of the signal from heat and smoke (e.g. Jones Hall and South Residence Hall).

VIII.    Kitchen Extinguishing Systems
a.    Kitchen extinguishing systems are also considered fixed extinguishing systems. They are used in areas that contain cooking equipment (e.g. fryers) that uses oil or grease and could be highly susceptible to fire. These systems are designed to saponify the oils/grease and cool the entire mass of oil below its auto-ignition point thus extinguishing the fire, will be inspected every 6 months by an approved outside contractor to ensure their operation is sufficient.  

IX.    Fire Alarms/Pull Stations and Alarms for Sprinkler Systems
a.    Facilities in areas where municipal fire departments are available may have an alarm box located in the building. Other facilities, which may contain several buildings, may have auxiliary alarm boxes connected to the municipal fire alarm system at various points in the facility.
b.    Water sprinkler systems are equipped with an audible alarm designed to alert employees that the systems have been activated. Water sprinkler system alarms can be activated either by the heat detection system or by the flow of water through the sprinkler. Therefore, the alarm will sound approximately the same time water is discharged from the sprinklers.

X.    Open Flame
a.    Lighted candles or other open flames are NOT permitted in any University facility (outside of specific labs) unless under special supervision of properly authorized personnel trained in fire safety. No candles or burning incense in dorm rooms or offices and no item should be lit and left to smolder. In laboratories, no flame should be left unattended. Related to the open flames, smoking of any kind is not allowed anywhere on campus. 

XI.    Sterno Fuel for Food Warming
a.    Sterno type gel fuel may be used for food warming at approved events, as long as the following guidelines are adhered to:
    i.    A trained attendee with access to a type “ABC” portable fire extinguisher must be present whenever Sterno type gel fuel is used.
    ii.    Never use water to extinguish a fire involving Sterno type gel fuel since water may actually spread the fire.
    iii.    No combustible materials (paper, baskets, table decorations, table linens, etc.) may be placed within six (6) inches of a burning fuel container.
    iv.    Use CAUTION when handling OPEN FLAME products:
        1.    Use a blunt object, such as a spoon, to pry off the lid. Never use sharp knife to pry off the lid.
        2.    Remove excess gel from lid if it is being used as a regulator.
        3.    Wash fuel residue from hands.
        4.    Place the can securely underneath the chafing dish or beverage urn before lighting.
        5.    Use a long handled match or butane lighter to light the can.
        6.    Never use a lit can to light another can, carry lit cans or carry chafing dishes or beverage urns with lit cans
        7.    Never allow loose clothing, napkins or tablecloths near flame or hair to fall near flame.
        8.    Use a snuffer paddle, regulator or saucer to extinguish the flame. Never use hands to extinguish flame or blow out flame of Sterno type gel fuel to extinguish.
        9.    Wait until the can is cool before touching.
    v.    Small amounts of Sterno gel type fuel shall be stored in closed containers in a cool dry place (40-120°F) away from sources of heat or open flame. If large amounts of Sterno gel type fuel is to be stored in a University building please contact the Emergency Management and EH&S Office to determine appropriate storage requirements.

XII.    Holiday and Other Decorations
a.    The following regulations concerning Christmas and holiday decorations have been established because of the extreme dangers of fire present during the holiday season:
    i.    No live Christmas trees will be permitted in any University building for decorative purposes.  Noncombustible artificial trees will be acceptable if wiring for lights and decorations meet UL requirements and have been approved by the Facilities.
    ii.    No evergreen or cedar branches, combustible cotton, combustible angel hair or other combustible materials are permitted to be used on the doors, bulletin boards or other exit hallway locations for decorations.
b.    Any decorations on campus shall meet the following requirements:
    i.    Be of fire resistant material, preferably noncombustible material such as foil, metal or glass.
    ii.    No decorations shall obstruct any exits, smoke detectors, fire alarms, pull stations (alarms), fire extinguishers or sprinklers.
    iii.    Outdoor decorations shall be self-supporting and be placed as far away from buildings or additions as possible. In NO CASE shall decorations be less than 10 feet from a building or addition. 
    iv.    All decorations shall be removed within 48 hours following the event for which they are used.

XIII.    Electrical Wiring and Appliances
a.    All extension cords and wiring must be approved by the facilities before power is authorized. Access to all electrical breaker panels should be clear and open at all times. The use of extension cords, power strips, surge protectors and similar devices shall be limited should be review by Facilities and/or Environmental Health & Safety. Under no circumstances shall “daisy chaining” of surge protectors or power strips be permitted as a permanent solution to satisfy power requirements. Double or triple plugs to expand capacity are not permitted and extension cords must be UL listed and a minimum of 16-2 cord.
b.    Only those persons who are qualified and authorized may install, fabricate, repair, test, calibrate, or modify electrical wiring, devices, systems, or equipment. Qualification and authorization to perform electrical or electronics work is based on a combination of formal training, experience, and on-the-job training. The qualified individual has had sufficient, documented training and experience and can demonstrate appropriate knowledge and skills to be able to work on electrical equipment, whether energized or de-energized.
c.    Cooking appliances with a heating element (e.g. crock pot, toaster, Foreman grill, etc.) and microwaves are not allowed in students’ rooms in the North Residence Hall, however a community microwave is available for use on each floor.
d.    Immediately report malfunctioning electrical devices to resident assistants, Public Safety, or Facilities.
e.    Portable space heaters for use in office spaces by faculty and staff must be approved by facilities and environmental health & safety before use. Portable space heaters are not permitted to be used in resident rooms, classrooms, study rooms, or campus spaces.

 XIV.    Basic Fire Procedures
a.    Fires are categorized as either small or large scale fires regardless of source or type.
b.    A small fire is considered to be something the size of a standard office trash can or less and can be handled with one fire extinguisher.  The procedure for handling a small fire is as follows:
    i.    Have someone notify Public Safety
    ii.    If trained, extinguish the fire with the appropriate extinguisher remembering to keep the exit to your back.
    iii.    If the fire is not extinguished with one fire extinguisher or with in 1 minute, then exit the area, close the door, activate the fire alarm and tell others as you evacuate the building.
c.    A large fire is considered to be anything greater than a standard office trash can or requires the use of more than one fire extinguisher. The procedure for handling a small fire is as follows:
    i.    Notify Public Safety
    ii.    Close the door, activate the pull station and tell others as you evacuate the building.
    iii.    Evacuate to emergency assembly point and report to the Building Emergency Coordinator (BEC). The BEC will notify Public Safety or the Fire Department of the number and location of missing persons. Do not return to the building.
    iv.    Wait at the assembly point for further instructions and follow directions explicitly.
d.    The use of the fire extinguisher to put out a fire is voluntary. Do not use the fire extinguisher, unless you have been trained and feel comfortable, have backup, and have called Public Safety to notify the Fire Department. Leave the area if the fire is not extinguished with one fire extinguisher or in one minute.
e.    Suggestions for the use of a fire extinguisher: PASS
    i.    Pull the pin
    ii.    Aim the extinguisher at the base of the flame
    iii.    Squeeze the trigger
    iv.    Sweep from side to side at the base or source of the fire, and approach the fire slowly, keeping an exit behind your back
    v.    Fire extinguisher must be held in an upright, vertical position
f.    Any employee, student, or visitor that becomes aware of a fire that requires activation of the building systems shall immediately activate the building fire alarm system. The fire alarm system will in turn notify all building occupants that a fire emergency exists. This is accomplished through sounding an audible alarm and a visual flashing light. All employees, students and visitors will regard any activation of a fire alarm as a true fire emergency unless there has been previous notification of a test being conducted.

XV.    Facilities/Emergency Management and EH&S
a.    The Director, Facilities management is responsible for budgeting and ensuring that adequate funds are available for the purchase of portable fire extinguishers for various UHSP work places. For UHSP facilities with water and/or kitchen extinguishing systems, Facilities will ensure service contracts are in place for the required periodic servicing of these systems and the audible alarms associated with them.  The Facilities Director will also coordinate and maintain the annual contract with a vendor to perform the annual inspections and hydrostatic testing schedule that is required for each portable fire extinguisher. Facilities will ensure that fire extinguishers are replaced after each use. They will also ensure that damaged or defective fire extinguishers are removed from service and replaced.  Facilities will maintain a supply of replacement portable fire extinguishers including those rated for types A, B, and C hazards. Class D extinguishers will be made available only after consultation with Emergency Management and EH&S.
b.    The Emergency Management Coordinator is responsible for identifying the employees affected by this safety policy and procedure. The Emergency Management Coordinator will obtain and coordinate the required training for the affected employees. The Emergency Management Coordinator will also audit the UHSP fire protection program for compliance with this safety policy and procedure. The Emergency Management Coordinator will also ensure that monthly is performed on the portable fire extinguishers. The records of inspections and testing shall be maintained electronically and retained in a database. The Emergency Management Coordinator will develop or secure the required training and will work with Facilities to ensure that all newly purchased fire extinguishers comply with fire protection standards and this safety policy and procedure.

XVI.    Supervisors
a.    Supervisors will ensure that employees are trained in the general principles of fire protection and the use and function of various types of fire protection equipment.
b.    Supervisors will ensure that fire extinguishers are recharged after each use by reporting it to Facilities. They will also ensure that damaged or defective fire extinguishers are reported to Facilities so they can be removed from service and replaced.

XVII.    Employees
a.    Employees are responsible for reporting fire hazards to their supervisors. Actual fires will be reported immediately to Public Safety at 446-SAFE (7233). Public Safety will contact local fire department if they have not already been called due to the triggering of one of the fire system’s alarm/sensor components. Employees will not attempt to extinguish fires beyond the incipient stage.

XVIII.    Conclusions
a.    All UHSP departments will work collaboratively to ensure plans for future renovations or new construction projects include the required fire protection systems and fire-rated building components. We will assume all inspection, testing, and maintenance responsibilities for new water-based fire protection systems, pre-engineered restaurant fire extinguishment systems, special hazard fire extinguishment systems and portable fire extinguishers upon completion of building projects to ensure these systems are maintained in accordance with State Fire Codes and to ensure the operational integrity of each system.
b.    Fire Safety Education and Training
    i.    Fire extinguishers are located in each of the buildings on campus, to include the Alumni House and may only be used in case of a fire. Fire extinguisher safety training is provided at the beginning of the academic year and to faculty and staff in the fall and spring. Additional fire safety training is available upon request by contacting the Emergency management coordinator.
c.    Reporting a Fire
    i.   If you discover a fire, use a fire extinguisher.  You should immediately evacuate the building, sound the alarm if it isn’t activated, call Public Safety at ext. 7233 (SAFE) and advise the dispatcher of the situation. In the event the fire has been extinguished, you should contact Public Safety to make them aware of the incident.  All fires will be investigated to determine the cause and recorded on a fire log and is later published in the Annual Fire Safety Report before the 1st October each year. Ultimately, this information allows the University to take proactive measures to reduce future occurrences.





Approval of faculty and staff space heaters utilized in offices.



Policy Contacts:


Contact Information

Carlin Harp


Eric Knoll