Information
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Tag/Bag Number:
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Harness User Name
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Conducted on
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Prepared by
Harness Info:
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HARNESS Date of Manufacture:
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PREVIOUS inspection Date:
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HARNESS Brand and Model #
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HARNESS Serial #
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HARNESS Lot #
Hardware:
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Label Attached to Harness and Fully Legible
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Impact Indicators Intact?
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Buckles in Place?
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D Rings in Place?
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Back Pad in Place?
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Loop Keepers in Place?
Hardware Condition:
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Free of Damaged or Worn Parts?
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Free of Broken or Bent Parts?
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Free of any Sharp Edges?
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Free of Burrs?
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Free of Cracks?
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Free Corrosion?
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Parts free of distortion and elongation?
Webbing:
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Free of Grease, Paint, Oil and excessive Dirt?
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Free of Cuts?
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Webbing free of Frays?
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Free of Broken Fibers?
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Free of Broken Stitches?
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Free of Tears?
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Free of Abrasions?
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Free of Mold?
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Free of Burns?
Lanyard Info:
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LANYARD Date of Manufacture:
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PREVIOUS inspection Date:
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LANYARD Serial #
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LANYARD Brand and Model #
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LANYARD Lot #
Hardware Condition:
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Label Attached and Fully Legible<br>
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Is the impact indicator intact?
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Gate Meets CSA 3600lb requirements
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Free of Damaged or Worn Parts?
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Free of Broken or Bent Parts?
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Free of any Sharp Edges?
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Free of Burrs?
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Free of Cracks?
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Parts free of distortion and elongation?
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Free Corrosion?
Webbing:
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Free of Grease, Paint, Oil and excessive Dirt?
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Free of Cuts?
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Webbing free of Frays?
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Free of Broken Fibers?
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Free of Broken Stitches?
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Free of Abrasions?
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Free of Mold?
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Free of Burns?
Dual Lanyard Info:
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LANYARD Date of Manufacture:
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PREVIOUS inspection Date:
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LANYARD Serial #
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LANYARD Brand and Model #
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LANYARD Lot #
Hardware Condition:
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Label Attached and Fully Legible<br>
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Is the impact indicator intact?
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Gate Meets CSA 3600lb requirements
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Free of Damaged or Worn Parts?
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Free of Broken or Bent Parts?
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Free of any Sharp Edges?
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Free of Burrs?
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Free of Cracks?
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Free Corrosion?
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Parts free of distortion and elongation?
Webbing:
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Free of Grease, Paint, Oil and excessive Dirt?
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Free of Cuts?
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Webbing free of Frays?
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Free of Broken Fibers?
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Free of Broken Stitches?
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Free of Abrasions?
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Free of Mold?
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Free of Burns?
Self Retracting Lanyard / Lifeline Info:
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SRL Date of Manufacture:
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PREVIOUS inspection Date:
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SRL Serial #
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SRL Brand and Model #
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SRL Lot #
SRL Condition:
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Label Attached and Fully Legible<br>
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Is the impact indicator intact?
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Webbing Free of Grease, Paint, Oil and excessive Dirt?
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Webbing free of frays?
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Are all screws and fasteners tight and in place?
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Housing free of any distortion, cracks, and other damage?
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Lifeline free of cuts, burns, tears, abrasions, frays, excessive soiling, and discoloration?
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Parts free of distortion and elongation?
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Does lifeline lock when quickly deployed?
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Does lifeline retract fully with no slack after full deployment?
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Are hooks & carabiners free of physical damage and corrosion and operate freely?
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Are all labels present and fully legible?
Overall inspection Info:
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IF INSPECTION REVEALS ANY DEFECTIVE CONDITION, REMOVE FROM SERVICE AND DESTROY.
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Signature of Inspector