This form is to be used by the fire engineer to summarise the performance solution issues in the performance solution report (PSR) and identify whether consultation or assessment by Fire and Rescue NSW (FRNSW) has occurred on each issue.

Premises

Premises name	Premises name (if applicable)
Street address	Primary street address
Premises suburb	Premises suburb name

Performance solution report

Company name	Enter organisation name
Fire engineer name	Enter name of accredited fire engineer	Registration number	Number
PSR reference	Enter ref. number	Version	Version	Date issued	Select date

Performance solution issues

No.	Title of performance solution issue or DtS departure	DtS Clause(s)	Performance Requirement(s)	Assessment Method	Status	Date
A2.2(1)	A2.2(2)
Enter issue	Select	Select
Enter issue	Select	Select
Enter issue	Select	Select
Select	Select