ELEVATED WORK PLAN (example) Re-Released: 09/2013

Provide detailed written plan, which corresponds with the project schedule. Include drawings and sketches for each
phase.

Location of
work:

Prepared By: Date Prepared:

Supervised by: (Foreman)

Statement of Company Policy:

Fall Protection Systems/ Procedures to be Used on this Project: E.G. Arial Boom Lifts, ½ inch Cable Top Rail
and Mid-rail, Cable Rat Line Designed for fall protection purposes (list # of people allowed to tie off to it), shock
absorbing lanyards with “beamers”, etc.

Implementation of Fall Protection Plan: Where does plan apply (E.G. Walls, Floor Holes, Unguarded Work
Platforms, Ladders, Roofs, Scaffolds, Rigging, Rebar Guarding, Ladders).

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 ELEVATED WORK PLAN (example) Re-Released: 09/2013

Training: Who is trained in the above procedures, who is responsible for training them, and when were they last
trained?

Enforcement: How will you enforce the above policies/ procedures? Describe specific disciplinary policy f or f all
protection infractions.

Incident Investigations : Reporting, Finding Causes, Prevention

Changes to Plan: Who do changes go through, who reviews changes, additional training needed?

Rescue Plan: Retrieval method for employee who may become suspended due to an elevated work fall. (Examples:
aerial lift, boom basket, mechanical retrieval device.)

CONTRACTOR SIGNATURE___________________________ Date ______________