Fall Protection Inspection Form

• Conducted on

  Date

• Prepared by

• Location
  Address

• Select date

  Date

• Please take a photo of harness and lanyard.

  Media

• Office Location Equipment Belongs to:

Harness Info:

• Label Attached To Harness

  Yes

  No

  N/A

• Label Fully Legible

  Yes

  No

  N/A

• Harness Date of Manufacture:

• Harness Serial Number:

• Harness Lot Number

• Harness Model Number:

Hardware:

• Buckles in Place?

  Yes

  No

  N/A

• D Rings in Place?

  Yes

  No

  N/A

• Back Pad in Place?

  Yes

  No

  N/A

• Loop Keepers in Place?

  Yes

  No

  N/A

Hardware Condition:

• Free of Damaged or Worn Parts?

  Yes

  No

  N/A

• Free of Broken/Bent Parts/Cracks?

  Yes

  No

  N/A

• Free of any Sharp Edges/Burrs?

  Yes

  No

  N/A

• Parts Free of Distortion and Elongation?

  Yes

  No

  N/A

• Free From Corrosion?

  Yes

  No

  N/A

Webbing:

• Free From Cuts/Frays/Broken Stiches/Tears/Abrasions?

  Yes

  No

  N/A

• Free of Mold/Dirt?

  Yes

  No

  N/A

• Free of Burns/Weld Splatter?

  Yes

  No

  N/A

Single or Double Lanyard?

• Lanyard:

  Single Lanyard

  Double Lanyard

• Lanyard Date of Manufacture

• Lanyard Serial Number:

• Lanyard Model Number:

• Make:

Hardware Condition:

• Free of Damaged or Worn Parts?

  Yes

  No

  N/A

• Free of Broken/Bent Parts/Cracks?

  Yes

  No

  N/A

• Free of any Sharp Edges?

  Yes

  No

  N/A

• Free of Burrs?

  Yes

  No

  N/A

• Free from Corrosion?

  Yes

  No

  N/A

Webbing:

• Free From Cuts/Frays/Broken Stiches/Tears/Abrasions?

  Yes

  No

  N/A

• Webbing Free From Mold/Dirt?

  Yes

  No

  N/A

• Webbing Free From Burns/Welding Splatter?

  Yes

  No

  N/A

Hooks / Carabineers

• Free of Corrosion & Physical Damage?

  Yes

  No

  N/A

Ascender:

• Serial Number

• Date of Manufacture:

• Model Number:

• Make::

Hardware Condition

• Free of Physical Damage and Deformities?

  Yes

  No

  N/A

• Free of Corrosion?

  Yes

  No

  N/A

• All Markings Present and Legible?

  Yes

  No

  N/A

• Are Locking Levers Free of Damage and Operate Smoothly?

  Yes

  No

  N/A

Overall Inspection Info:

• IF INSEPCTION REVEALS ANY DEFECTIVE CONDITION, REMOVE FROM SERVICE AND DESTROY AFTER NOTING REMOVAL FROM SERVICE!

• Signature of Inspector:

• Add signature

  Sign