Annual Program Review - Working at Heights

• Conducted on

  Date

• Prepared by

• Location
  Address

Documents Reviewed

• Completed Permits

• Is the site using the standardized permits?

  Yes

  No

  N/A

• How many working at heights permits are issued per year?

  0

  1-10

  11-25

  26-50

  50+

• Has the site been reviewed by a 3rd party to assessment all fall risk?

  Yes

  No

  N/A

• Have the integrity of fall arrest equipment and anchor points been maintained?

  Yes

  No

  N/A

• Have affected employees been trained in fall from heights risk, proper use of related equipment, and current regulations?

  Yes

  No

  N/A

• Have control equipment and methods needed to prevent fall from heights during routine activities been identified?

  Yes

  No

  N/A

• Have fall rescue plans been developed?

  Yes

  No

  N/A

• Is equipment to support working at heights meeting regulations and is in good working condition?

  Yes

  No

  N/A

• Is fall protection requires that fall hazards are controlled when working at four (4) or more feet for General Maintenance Activities and 6 feet for all Construction Activities?

  Yes

  No

  N/A

• Work at an unprotected edge shall also be controlled at fifteen (15) feet for all General Maintenance Activities and 6 feet for all Construction Activities.

  Yes

  No

  N/A

• Are personal fall arrest system or components subjected to impact loading such as sustaining a fall shall be immediately removed from service and destroyed?

  Yes

  No

  N/A

• Are the Personal fall arrest systems must be inspected prior to each use?

  Yes

  No

  N/A

• Is a documented annual inspection by a competent person will be conducted on all personal fall arrest system components to ensure integrity of equipment?

  Yes

  No

  N/A

• Is all personal fall arrest system components must be used in accordance with the manufacturer’s instructions to include but not limited to use, care, storage, functional lifespan, inspection, etc.?

  Yes

  No

  N/A

• Do personal fall arrest system components deemed not fit for service shall be removed from service and rendered not usable (i.e., destroyed) or returned to the manufacturer for repair?

  Yes

  No

  N/A

• Are fall protection equipment made of synthetic fiber removed from service after 5 years, unless otherwise specified by the manufacturer?

  Yes

  No

  N/A

• Are scaffolds designed, erected and dismantled by qualified persons and shall be constructed and loaded in accordance with the design and/or manufacturer’s specifications?

  Yes

  No

  N/A

• Does a designated qualified competent person inspect erected scaffolds daily?

  Yes

  No

  N/A

• Does a designated qualified person shall inspect mobile platforms daily?

  Yes

  No

  N/A

• Are operators of scissor and aerial lifts required to receive a health evaluation by Occupational Health initially and every three years thereafter?

  Yes

  No

  N/A

• Are evaluations shall be done the same year as the employee is scheduled for recertification?

  Yes

  No

  N/A

• What training do employees working at heights required to take?

  Yes

  No

  N/A

• Permit - Are responsiblities following the matrix in the TSS?

  Yes

  No

  N/A

• Permit - Do the roles of the people listed and signing the permit meet the competency requirements?

  Yes

  No

  N/A

• Are permits filled out completely and correctly, and do they meet the time limit requirements and extention validity?

  Yes

  No

  N/A