Chaparral Energy Fall Protection Audit

• Field Office

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel Present

Equipment User

• Who is this equipment assigned to?

• Is this equipment assigned to a specific vehicle? If so, what is the vehicle number?

Harness Information

• What is the harness serial number?

• Harness Size?

  S

  M

  L

  XL

  XXL

• Is the harness free of any tears or rips?

  Yes

  No

  N/A

• Harness condition?

  Safe

  At Risk

  N/A

• Condition of the buckles?

  Safe

  At Risk

  N/A

• Condition of the straps?

  Safe

  At Risk

  N/A

• Condition of the D ring?

  Safe

  At Risk

  N/A

• Condition of the label?

  Safe

  At Risk

  N/A

Lanyard Information

• What is the lanyards serial number?

• Type?

  double legged

  single legged

• Length?

  6 ft

  8 ft

• Condition of the hook?

  Safe

  At Risk

  N/A

• Is the lanyard free of tears or rips?

  Yes

  No

  N/A

• Condition of the carabiner?

  Safe

  At Risk

  N/A

Talon SRL Information

• What is the serial number on the self retracting lifeline?

• What is the length of the self retracting lanyard?

• Condition of the hook?

  Safe

  At Risk

  N/A

• Condition of the cable?

  Safe

  At Risk

  N/A

• Condition of the carabiner?

  Safe

  At Risk

  N/A

Auditor Verification

• Add signature

  Sign