Information

  • Conducted on:

  • Building Name:

  • Building Address:
  • City:

Description of tasks to be done:

  • Task:

Fall Protection Plan

Fall Protection Plan

  • Identify all existing & potential fall hazards associated with the task activity.

  • Potential to fall from heights

  • Can materials be dropped from height into a high traffic area

  • Can ropes be sheared

  • Can ropes slide

  • Additional Fall Hazards

  • Hazard
  • Hazards:

Identify the fall protection systems to be used at the work site to protect workers from the fall hazard (i.e. travel restraint, personal fall arrest system, safety net, control zone, etc)

  • Fall Protection System to be Used:

  • Anchors:

Clearance Required

Clearance Distance(s) to be Confirmed

  • L = Initial Length of lanyard, energy absorber and connecting hardware
    B = Height of D-ring measured from the worker’s feet
    C = Distance between anchor point and unguarded edge
    EAE = Energy absorber extension (typically 4 feet)
    DS = D-ring slippage (typically 1 foot)
    SM = Safety margin (typically 2 feet)

  • Free Fall Distance (FFD = L + B - C):

  • Total Fall Distance (TFD = FFD + DS + EAE):

  • Clearance Distance (CD = TFD + B + SM)

  • Clearance distance is ≤ to the obstruction below

Rescue Procedures

Describe the procedures that will be followed if a worker falls and needs to be rescued.

  • Identify the Safe Work Practice and/or Safe Job Procedure developed for the task.

  • Identify Emergency Response Procedures:

Signatures

  • I hereby certify that all information is accurate and that an actual inspection was conducted.

  • Crew Manager's Printed Name & Signature

  • Worker's Printed Name & Signature

  • Worker
  • Worker:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.