Title Page
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Conducted on
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Prepared by
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Location
Observation
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Employee Name:
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Employee Number:
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Department:
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Observer:
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Fall Protection Equipment Utlilized
- Fall Harness
- Lanyard
- Retractable Lifeline
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Was the Harness / Lanyard / or Retractable Lifeline inspected properly and safe for use? (no visible damage, all components were working, etc)
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Did the employee Donn the Harness / Lanyard / or Retractable Lifeline properly? (D-ring between shoulder blades, straps secured and not to tight or loose, etc)
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Was the Lanyard or Retractable Lifeline secured properly to a connecting point?
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Was a proper connecting point utilized for the task?
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Employee performed the Fall Protection task safely?
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Pass / Failed the observation?
