General Information
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Site name
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Issue date
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Description of work
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Prepared by
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Signature
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Competent person responsible for rescue (name)
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Contact phone number
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Would you like to list another competent person responsible for rescue?
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Name of additional competent person
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Contact phone number for additional competent person
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
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Are there more teammates to list?
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Name of teammate working from height
Rescue Plan
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Reason(s) Personal Fall Arrest System (PFAS) is required (Select all that apply)
- Hole
- Shaft
- Tank or Vessel
- Leading Edge
- Building Exterior
- Roof
- Tower Crane
- Other
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List other
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Consider alternate means and methods to perform the assigned task(s) without fall exposure such as installing guardrails or utilizing scaffolding or aerial lifts.
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Maximum working height (in feet and inches)
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Are there any restrictions that would hinder the rescue of a fallen teammate (select all that apply)?
- None
- Temperature extreme - hot
- Temperature extreme - cold
- Surface conditions
- High winds
- Rain
- Sleet, hail or snow
- Confined space
- Inadequate lighting
- Gated parking lot
- Access controlled doors
- Ground level obstructions
- Inaccessible area(s)
- Hazardous operations
- Multi-level roof tops
- Structural offsets
- Dangerous wildlife
- Vehicular traffic
- Adjacent power lines
- Exhaust systems
- Structural integrity of building
- Structural integrity of equipment
- Landslide
- Other
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Please list other restrictions
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Please describe how the selected restrictions are mitigated to ensure a prompt rescue of a fallen teammate.
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Approximate response time for on-site rescue team (in minutes)
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Approximate response time for off-site rescue team (in minutes)
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Are there any hazards to the teammate(s) working at height (select all that apply)?
- None
- Power lines
- Exhaust systems
- Impalement
- Entanglement
- Sharp leading edges
- Wildlife
- Vehicular traffic
- Dangerous equipment
- Dangerous operations
- Potentially hazardous atmosphere
- Congested work area
- Temperature extreme - Cold
- Temperature extreme - Hot
- Severe weather
- Cranes in operation
- Inadequate lighting
- Inadequate communication methods or devices
- Chemical
- Structural integrity
- Water
- Other
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Please list other hazards
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Please describe how the selected hazards are mitigated to ensure the teammate can safely work at height?
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How will the competent person(s) be alerted if a teammate working at height needs to be rescued (select all that apply)?
- Visual - On site
- Visual - Camera or electronic device
- Verbal
- Radio
- Telephone
- Horn or other sounding device
- Other
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Please describe
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In the event of a rescue from maximum height, what rescue methods and equipment will be used (select all that apply)?
- Local emergency services
- Aerial lift
- Self-rescue suspension trauma straps
- Self-rescue ladder
- Ladder assisted rescue
- Rope rescue system
- Crane or derrick
- Self-rescue controlled descent system
- Rescue pole or hook
- Remote activated descent system
- Other
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In the event of a rescue, is the necessary equipment on-site?
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Work at height is prohibited until the necessary equipment is available on-site.
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In the event of a rescue, have all personnel been trained in the proper use of the equipment and methods of their use?
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Work at height is prohibited until all affected personnel have been trained
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Are there any additional concerns regarding this Fall Rescue Plan?
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Please describe
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Have all affected teammates reviewed and understood the Fall Rescue Plan?
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Work at height is prohibited until all affected teammates have reviewed and fully understand the Fall Rescue Plan
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All hazards and concerns have been addressed, and appropriate mitigations are in place to ensure that teammates working at height can perform their duties safely. In the event of a fall, proper rescue measures are established to ensure the teammate can be quickly and safely rescued.
