Information
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Document No.
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Audit Title
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Plant
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Audit Date
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Prepared by
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Personnel
- Job Task
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Enter a detailed description of the fall hazard here. Include location, equipment involved, department, and any other pertinent information required for identification.
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Severity: How many feet (meters) above the next highest working surface is the employee required to conduct work?
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The hazard is < 4 feet (1.22 m) above the next lowest working surface.
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The hazard is 4ft (1.22m) - 10ft (3.05m) above the next lowest working surface.
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The hazard is 10ft (3.05m) - 15ft (4.57m) above the next lowest working surface.
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The hazard is 15ft (4.57m) - 25ft (7.62m) above the next lowest working surface.
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The hazard is > 25ft (7.62m) above the next lowest working surface.
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Frequency: What is the frequency of unprotected work from this height? Unprotected work includes the use of a harness or other fall protection equipment. It does not include work where an engineering control prevents exposure. Pick the answer that best matches the actual frequency.
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Employees are exposed to this hazard less than once per year.
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Employees are exposed to this hazard two to five times per year.
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Employees are exposed to this hazard six to twelve times per year.
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Employees are exposed to this hazard once a week to once a month.
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Employees are exposed to this hazard twice a week or more.
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Hazard Multiplier: How many additional hazards exist that could increase the liklihood of injury in the event of a fall? (ex. chemical exposure, swing hazards, dangerous equipment below, remote work)
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There are zero additional hazards.
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There is one additional hazard.
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There are two additional hazards.
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There are three additional hazards.
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There are four or more additional hazards.
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Describe all additional hazards in detail. Ensure there are as many descriptions as there are number of identified additional hazards.
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Is there a feasible engineering/elimination solution for this hazard?
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Describe high level details of the proposed solution(s).
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Describe other controls that may need to be implemented (ex. PPE, administrative,etc.)
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Are appropriate tie-off points available?
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Signature of Auditor
