Fall Protection and Rescue Plan

Create a Fall Protection and Rescue Plan

Date

Job Location

Completed by?

Email of person completing the plan.

Do all workers have their Working at Heights certification on hand?

Yes No

JSA complete? (Attach photo of JSA)

Yes No

Attach photo of JSA

Estimated time to complete job?

Have the following inspections been completed:

Periodic harness inspection Pre-use harness inspection Periodic lanyard inspection Pre-use lanyard inspection Periodic miscellaneous fall protection hardware and temporary anchoring devices inspection Pre-use miscellaneous fall protection hardware and temporary anchoring devices inspection Periodic fall protection system inspection (if applicable) Pre-use fall protection system inspection (if applicable)

Identify the type of fall protection system being used:

Other:

Does the fall protection system comply with CSA standards?

Yes No

Lanyard Length (ft)

Shock Absorber Length (ft)

Worker Height (ft, in)

Safety Factor (ft)

Total Fall Distance (ft, in)

Are you working where there is potential for swing fall as a result of anchor placement?

Yes No

List all potential fall hazards, their level of risk (low, med, high), and the controls below:

Have you reviewed all the appropriate rescue procedures?

Yes No

Describe the rescue plan in full:

Document Emergency Contact Numbers

Describe the rescue equipment being used:

Has the rescue equipment been inspected?

Yes No

Have all personnel working on the job reviewed the rescue plan?

Yes No

List the names of all parties who have reviewed the procedure, and the date.

Approved by?

Supervisor Acknowledgement

I hereby confirm that I have reviewed the Fall Protection and Rescue Plan in full, including all identified hazards, control measures, inspection requirements, and emergency procedures. I understand the responsibilities outlined within this plan and will ensure that all workers under my supervision are informed and compliant with the safety measures described.

Create a Fall Protection and Rescue Plan

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