TDINDUSTRIES Fall Protection Equipment Inspection

• TDIndustries Fall Protection Inspection

• Fall Protection Bag No.

• Conducted on

  Date

• Prepared by

• Location
  Address

Harness Info:

• Label Attached to Harness<br>

  Yes

  No

  N/A

• Label Fully Legible

  Yes

  No

  N/A

• HARNESS Date of Manufacture:

• HARNESS Serial #

Hardware:

• Buckles in Place?

  Yes

  No

  N/A

• D Rings in Place?

  Yes

  No

  N/A

• Back Pad in Place?

  Yes

  No

  N/A

• Loop Keepers in Place?

  Yes

  No

  N/A

Hardware Condition:

• Free of Damaged or Worn Parts?

  Yes

  No

  N/A

• Free of Broken or Bent Parts?

  Yes

  No

  N/A

• All Buckle Springs Loose?

  Yes

  No

  N/A

• Free of any Sharp Edges?

  Yes

  No

  N/A

• Free of Burrs?

  Yes

  No

  N/A

• Free of Cracks?

  Yes

  No

  N/A

• Parts free of distortion and elongation?

  Yes

  No

  N/A

• Free Corrosion?

  Yes

  No

  N/A

Webbing:

• Free of Cuts?

  Yes

  No

  N/A

• Webbing free of Frays?

  Yes

  No

  N/A

• Free of Broken Fibers?

  Yes

  No

  N/A

• Free of Broken Stitches?

  Yes

  No

  N/A

• Free of Tears?

  Yes

  No

  N/A

• Free of Abrasions?

  Yes

  No

  N/A

• Free of Mold?

  Yes

  No

  N/A

• Free of Burns?

  Yes

  No

  N/A

Self Retracting Lanyard / Lifeline Info:

• SRL Date of Manufacture:

• SRL Serial #

SRL Condition:

• Does impact indicator show no impacted or elongated?

  Yes

  No

  N/A

• Webbing free of frays?

  Yes

  No

  N/A

• Are all screws and fasteners tight and in place?

  Yes

  No

  N/A

• Housing free of any distortion, cracks, and other damage?

  Yes

  No

  N/A

• Lifeline free of cuts, burns, tears, abrasions, frays, excessive soiling, and discoloration?

  Yes

  No

  N/A

• Parts free of distortion and elongation?

  Yes

  No

  N/A

• Does lifeline lock quickly deployed?

  Yes

  No

  N/A

• Does lifeline retract fully with no slack after full deployment?

  Yes

  No

  N/A

• Are hooks & carabiners free of physical damage and corrosion and operate freely?

  Yes

  No

  N/A

• Are all labels present and fully legible?

  Yes

  No

  N/A

Cross-arm Strap

• Date of Manufacture:

• Serial #

Hardware Condition:

• Free of Sharp Edges?

  Yes

  No

  N/A

• Free of Burrs?

  Yes

  No

  N/A

• Free of Cracks?

  Yes

  No

  N/A

• Free Corrosion?

  Yes

  No

  N/A

• Are all labels present and fully legible?

  Yes

  No

  N/A

Webbing:

• Free of Cuts?

  Yes

  No

  N/A

• Webbing free of Frays?

  Yes

  No

  N/A

• Free of Broken Fibers?

  Yes

  No

  N/A

• Free of Broken Stitches?

  Yes

  No

  N/A

• Free of Tears?

  Yes

  No

  N/A

• Free of Abrasions?

  Yes

  No

  N/A

• Free of Mold?

  Yes

  No

  N/A

• Free of Burns?

  Yes

  No

  N/A

I understand that TDINDUSTRIES has provided me fall protection purchased by the company for use in my course of work. I also understand that it is my responsibility to pay for the replacement of fall protection listed above assigned to me that are lost or damaged due to negligence while in my possession. Additionally, I understand and agree that if my employment with TDINDUSTRIES (either voluntarily or involuntarily) is terminated and I fail to return the fall protection issued to me, I authorize TDINDUSTRIES to deduct the below cost from my final paycheck. Harness- $44.14 Self-retracting Lanyard - $162.57 Crossarm Strap - $18.46 Fall Protection Bag and rescue straps $40.20 Total - $271.14

• Signature of Partner

  Sign

Overall inspection Info:

• IF INSPECTION REVEALS ANY DEFECTIVE CONDITION, REMOVE FROM SERVICE AND DESTROY.

• Signature of Inspector

  Sign

• Signature of Partner

  Sign