1. Fall Protection Equipment Inspection

• Fall Protection Equipment being Inspected

• Conducted on

  Date

• Department/Location

• Prepared by

• Serial #

• Model #

• Manufacturer

• Equipment Owner

• DOM:

• In Service Date

• Photo of Equipment

  Media

Labels

• Attached and Readable

  Yes

  No

  N/A

• Damaged

  No

  Yes

  N/A

Impact Indicator (where applicable)

• Damaged

  No

  Yes

  N/A

• Deployed

  No

  Yes

  N/A

Plastic Keepers

• Missing

  No

  Yes

  N/A

• Damaged

  No

  Yes

  N/A

Stitching

• Cuts

  No

  Yes

  N/A

• Broken

  No

  Yes

  N/A

• Burned

  No

  Yes

  N/A

• Missing stitch patterns

  No

  Yes

  N/A

Webbing

• Frayed

  No

  Yes

  N/A

• Cuts, Tearing, holes

  No

  Yes

  N/A

• Burns

  No

  Yes

  N/A

• Knots

  No

  Yes

  N/A

• UV Damage

  No

  Yes

  N/A

• Discoloration

  No

  Yes

  N/A

• Paint

  No

  Yes

  N/A

• Grease/Grime

  No

  Yes

  N/A

• Missing/Damaged stitch pattern

  No

  Yes

  N/A

• Abrasion

  No

  Yes

  N/A

• Heat damage/glazing

  No

  Yes

  N/A

• Mold

  No

  Yes

  N/A

D-Ring

• Sharp edges

  No

  Yes

  N/A

• Cracked

  No

  Yes

  N/A

• Welded

  No

  Yes

  N/A

• Corroded

  No

  Yes

  N/A

• Bent

  No

  Yes

  N/A

D-Ring Plate

• Missing

  No

  Yes

  N/A

• Damaged

  No

  Yes

  N/A

Final Appraisal

• Fall Protection Status PASS/FAIL

  PASS

  FAIL

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