Annual Fall Protection Assessment

• A designated competent person shall complete this annual program assessment fill assessing each question below. If discrepancies are found, they will be documented by creating an action and tracked until completion. Reference 13.3.3

• The competent person will forward this assessment to the unit commander within 10 days of completion for signature and kept on file for no less than three years.

• Site conducted

  Select

• Conducted on

  Date

• Prepared by (Program Administrator/Competent Person)

CHAPTER 13, FALL PROTECTION CHECKLIST

• GENERAL INDUSTRY. Is fall protection provided whenever workers can fall four (4) feet or more? Reference 13.1.1

  Yes

  No

  N/A

• CONSTRUCTION INDUSTRY. Is fall protection provided whenever workers can fall six (6) feet or more during construction operations? Reference 13.1.2

  Yes

  No

  N/A

• Has the unit commander developed a Unit Fall Protection Policy? Reference 13.3.1

  Yes

  No

  N/A

• Has the supervisor ensured each authorized, qualified, and competent person using a fall protection/fall arrest system is trained and evaluated on proper use, application and inspection of fall protection/fall arrest systems? Reference 13.3.2.9.1

  Yes

  No

  N/A

• Has the commander designated in writing a competent person to administer the fall protection program and act as a liasion between the unit and the installation Occupational Safety Office? Reference 13.3.3.2.

  Yes

  No

  N/A

• Is the designated competent person(s) trained, provide and evaluate fall protection training, and, as applicable, develop, implement, monitor and evaluate the fall protection program to assure unit compliance? Reference 13.3.3.2.

  Yes

  No

  N/A

• Are trainers designated in writing by unit commanders? Reference 13.3.2.10

  Yes

  No

  N/A

• Has a fall hazard survey been conducted in all work area where employees are exposed to fall hazards? Reference 13.4.1

  Yes

  No

  N/A

• Are fall protection and rescue procedures documented specifically for each workplace and task they are applied to when the use of fall protection is required? Reference 13.5.1

  Yes

  No

  N/A

• Do authorized person(s) shall inspect PFAS prior to use.? Reference 13.8.2

  Yes

  No

  N/A

• Do supervisors ensure personal fall arrest systems components receive a thorough inspection at least quarterly? Reference 13.8.3

  Yes

  No

  N/A

• Are falls from heights, regardless of whether an injury or damage has occurred, reported to the servicing occupational safety office and investigated by a competent person and occupational safety personnel? Reference 13.8

  Yes

  No

  N/A

• Program Administrator/Competent Person:

  Sign

• Commander:

  Sign

• If your unit is scheduled an Occupational Safety Program Assessment during this fiscal year, please select N/A in the next question as the annual assessment of this program will be included in that report. If this is the case, this assessment may be completed without an Occupational Safety signature.

• When complete, select View Report on the right side of the screen. Then select PDF from the dropdown menu in the upper right of the screen to download the file.

• Occupational Safety has rated this program as:

  Select Met and Effective Met but Needs Minor Improvement Met but Needs Significant Improvement Not Effective N/A: See 24 month Occupational Safety Program Assessment for Fall Protection Program Rating

  • Met and Effective
  • Met but Needs Minor Improvement
  • Met but Needs Significant Improvement
  • Not Effective
  • N/A: See 24 month Occupational Safety Program Assessment for Fall Protection Program Rating

• Occupational Safety:

  Sign

• Occupational Safety: Conduct thorough annual review of fall protection program elements and documents annually in safety inspection/assessment reports. Reference 13.3.2.6.3