Evaluation: Fall Protection Authorized End User

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Person Being Evaluated

• Has the Authorized End User Employee received documented Fall Protection training in accordance with current ANSI Z359 or provincial standards?

  Yes

  No

  N/A

• Can the Authorized End User Employee identify existing and potential fall hazards in the work environment?

  Yes

  No

  N/A

• Can the Authorized End User Employee describe how the following fall protection equipment is utilized?

  Select Anchor Points Body Support Connectors Deceleration Effective Rescue Fall arrest/restraint

  • Anchor Points
  • Body Support
  • Connectors
  • Deceleration
  • Effective Rescue
  • Fall arrest/restraint

• Can the authorized end user employee describe and demonstrate how to properly inspect fall protection equipment?

  Yes

  No

  N/A

• Can the authorized end user employee describe and demonstrate how to properly inspect the following:

  Select Labels Anchors Webbing Stitching Rivets Hardware (d-rings, Fasteners, Etc.) Snaphooks/Carabiners

  • Labels
  • Anchors
  • Webbing
  • Stitching
  • Rivets
  • Hardware (d-rings, Fasteners, Etc.)
  • Snaphooks/Carabiners

• Can the authorized end user employee describe and demonstrate how to properly don, doff, adjust and wear his/her full body harness?

  Yes

  No

  N/A

• Can the Authorized End User Employee describe and demonstrate how to properly clean and maintain his/her full body harness?

  Yes

  No

  N/A

• Can the Authorized End User Employee describe and demonstrate how to properly store his/her full body harness?

  Yes

  No

  N/A

• Does the Fall Protection program provide for prompt rescue of employees in the event of a fall or shall assure the self-rescue capability of employees?

  Yes

  No

  N/A

• In the event of a fall, can the Authorized End User Employee describe the rescue plan (i.e. Self-Rescue, Assisted Self-Rescue using suspension trauma safety straps, Use of Ladders or Mechanical Lifts

  Yes

  No

  N/A

Evaluation Results

• Did the Authorized End User Employee pass the evaluation?

  Yes

  No

  N/A

• Comments: Why did the employee fail the evaluation?

• Employee Signature

  Sign

• Competent Person Signature

  Sign