The purpose of this form is to provide a safe system of work for the prevention of dropped and falling objects and to ensure that all persons working on Adaptable Training Partnerships worksites are protected form dropped and falling objects.
Is a task involves a hazard of potential dropped or falling objects. this form must be completed before commencing this task.
Date & Time:

Can you eliminate the hazard by doing the task at ground level?

If NO, Complete a Risk assessment and a housekeeping check of the area you are working in before you start the task.

What controls are in place to prevent falling objects?

Tool lanyards

Rubber tool grommets

Covering gaps in flooring, opening & grid mesh with appropriate material (e.g. safety mats, blankets, boards)

Toolboxes / Tool bags with lids / Tool Bags

Barrier Safety Mesh on handrails

Storage area (suitable bins, buckets, cages etc.)

Secure/Tie-down of equipment/objects and tools in windy conditions or inclement weather

OTHER; (please specify)

Hard barricading

Danger Tape with Information Tags

Exclusive Control Zone

"Working Above" signs


OTHER (please specify)

Is your work area "Drop Zone" barricaded - Every 4 meters up in height must be a minimum of 2 meters out from direct vertical drop to allow for deflection?

Have you checked and have communication with persons working above, below or in close proximity of each other?

NOTE: On completion of the task, conduct a thorough housekeeping and equipment check to ensure no loose items with the potential to fall are left at the work area.

Work Group Supervisor:
As workgroup supervisor I have verified that the above controls are in place and are effective in controlling the risk of dropped and falling objects.

Work Group Supervisor Name and Sign:
Date & Time:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.