Site Description, Location and Project:
Work Week & Year:
# of Crew Performing Elevated Work:
Days Elevated Work to Occur:
1. Inspect the site and submit this form each week by Wednesday noon to Apollo Admin.
2. Complete all sections on this form.
3. F.O.G. Plan must be in Foreman’s possession.
4. Any condition with a fall hazard with “Feet Off Ground” requires a Work Plan. If Feet are not required to leave ground this plan is not required.
Deck/Walking Working Surface Leading Edge
Scaffold and/or Staging: Falls From
Falls From Elevation
Working from MEWP
Roof or Floor Penetrations/Openings (2” or bigger must be protected over 12” requires Safety to review)
Open steel Beam/Truss/Framework:
Working Outside of Guardrail Systems (MEWP and Scaffold)
Tank/Vessel/Equipment: Falls Into
Parapet Wall Height of 39” or Greater
Non-Engineered Scaffold (SINGLE PLANK)
Hole Covers: Secured and Labeled
Fall protection Harness (If this is checked, Identify anchor point)
Self Retracting Lifeline (anchor point)
Embedded strut (anchor point)
Rope Grab (anchor point)
Horizontal life line (anchor point)
Stair Tower /Scaffold Ladder System
Install Caution Tape with Signage when needed
Install Danger Tape with Signage when needed
Block Access/Egress Points Into Work Zone
Provide Spotter/Flagger in Work Zone IF NEEDED
Use Life Lines/Retrieval Devices (tri pods, ect....)
Utilize Scaffolds or SINGLE PLANK
Initiate Emergency Response:503.613.4444 or ext 4.4444