Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Site Details
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Branch
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Date
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Job Location
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Job No.
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Supervisor
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Superintendent
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Supervisor to inspect the work area and at the beginning of the project and check-off the fall hazards that apply. A checkmark indicates a fall hazard that requires protective measures Check-off the controls that apply. Explain below what additional control measures were implemented. All workers must be instructed in the following procedures and sign the back confirming their review and understanding of this Fall protection plan. Superintendent to review, revise if necessary, sign, date and forward to Safety Specialist
Fall Hazard
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1. Working on unprotected leading roof edge
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Explain:
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Add media
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2. Working off aerial work platform
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Explain:
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Add media
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3. Assemble/dismantle or working off scaffold
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Explain:
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Add media
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4. Working off ladder
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Explain:
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Add media
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5. Holes in deck/roof
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Explain:
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Add media
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6. Swing stage
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Explain:
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Add media
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7. Sloped roof
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Explain:
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Add media
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8. Assemble/dismantle fall protection
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Explain:
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Add media
Fall Protection Measures
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9. Fall arrest protection
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Explain:
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Add media
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10. Fall restraint protection
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Explain:
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Add media
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11. Employees trained
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Explain:
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Add media
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12. Full body harness
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Explain:
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Add media
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13. Energy absorbing lanyard
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Explain:
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Add media
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14. Vertical lifeline
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Explain:
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Add media
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15. Horizontal lifeline
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Explain:
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Add media
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16. Restraint lifeline
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Explain:
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Add media
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17. Rope grab
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Explain:
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Add media
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18. Retractable lanyard
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Explain:
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Add media
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19. Anchor sling
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Explain:
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Add media
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20. 5000 lb anchor point
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Explain:
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Add media
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21. 900 lb anchor point
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Explain:
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Add media
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22. Guard handrails
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Explain:
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Add media
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23. Control zone
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Explain:
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Add media
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24. Barricade tape
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Explain:
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Add media
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25. AES Raptor
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26. Surface opening protection
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Explain:
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Add media
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27. PR 600
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Explain:
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Add media
Rescue Plan
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28. Fire Dept. high angle rescue
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Explain:
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Add media
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29. Additional AWP on site for rescue
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Explain:
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Add media
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30. Competent groundman to bring AWP down
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Explain:
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Add media
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Additional information, instruction, procedures regarding fall hazards, controls and/or rescue procedures:
Sign offs
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Name
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Employee Signature
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Superintendent Signature
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Safety Specialist Signature
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Date
