Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Person Being Evaluated
Untitled Page
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Has the Authorized End User Employee received documented Fall Protection training in accordance with current ANSI Z359 or provincial standards?
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Can the Authorized End User Employee identify existing and potential fall hazards in the work environment?
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Can the Authorized End User Employee describe how the following fall protection equipment is utilized?
- Anchor Points
- Body Support
- Connectors
- Deceleration
- Effective Rescue
- Fall arrest/restraint
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Can the authorized end user employee describe and demonstrate how to properly inspect fall protection equipment?
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Can the authorized end user employee describe and demonstrate how to properly inspect the following:
- Labels
- Anchors
- Webbing
- Stitching
- Rivets
- Hardware (d-rings, Fasteners, Etc.)
- Snaphooks/Carabiners
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Can the authorized end user employee describe and demonstrate how to properly don, doff, adjust and wear his/her full body harness?
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Can the Authorized End User Employee describe and demonstrate how to properly clean and maintain his/her full body harness?
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Can the Authorized End User Employee describe and demonstrate how to properly store his/her full body harness?
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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?
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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
Evaluation Results
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Did the Authorized End User Employee pass the evaluation?
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Comments: Why did the employee fail the evaluation?
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Employee Signature
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Competent Person Signature