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Fall Protection Plan

Company/Worksite Name: Date:

Address/Location:

1. Fall Hazards
Identify all existing and potential fall hazards associated with the work site.

2. Fall Protection systems to be used

Identify the fall protection systems to be used at the work site to protect workers from each fall hazard listed in
Section 1.

3. Anchors to be used during work

Identify the anchors that workers are to use (both engineered and improvised).

4. Fall clearance distance(s) to be confirmed

5. Procedures
Identify detailed procedures to assemble, inspect, use, maintain and dismantle the fall protection system(s)
identified in Section 2

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6. Emergency rescue plan
Person responsible to implement Rescue Plan?

Describe method of rescue:

Describe equipment necessary for rescue:

Identify workers trained to perform the rescue and their contact information:

How will workers be notified rescue is required?

First aid equipment required for rescue?

Who will notify external emergency services?

Rescue procedures:
Describe in detail what steps will be taken to rescue a worker who has fallen or requires rescue from a working height:

Developed by Approved by

Name: Name:

Signature: Signature:

Date: Date:

7. Worker signature list

Workers who sign this form acknowledge that they have reviewed and understood this Fall Protection Plan.

Date Print Name Signature Fall Protection Equipment

Training Received?

 Yes  No

 Yes  No

 Yes  No

 Yes  No

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