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Fall
Protection Work Safety Plan Form
Instructions:
A competent
person qualified to recognize fall hazards and who knows the fall protection
rules must write a plan for this worksite if a fall hazard(s) of 10 feet or
more will exist while employees are on site. Fill in the
blanks and check the appropriate boxes. A copy of
this plan must be on the worksite while employees are on site.
Worksite information
Company Name:
____________________________________ Date Prepared: ____/___/____
Worksite
Address: ________________________________________ City: ________________
Competent
Person to Supervise the Plan: __________________________________________
Where will
this plan will be posted? _______________________________________________
Fall protection methods
Identified Fall hazards
above 10 feet
Check all that apply
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Standard
Guardrails:
Are to be made from 2 X 4’s with posts spaced no more than 8’ apart.
The top rail must be 39" to 45" above the work surface with a midrail at
the half-way point and a toe board if workers will walk or work below.
The rail must withstand 200 pounds of pressure on the top rail in any
direction. Note: A guardrail does not protect a person
standing on a ladder, stilts, a box or other surface above the work
surface.
Additional Instructions: |
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Roof > 4/12 Pitch
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Roof =< 4/12 Pitch
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Skylight Opening
q
Roof Opening
q
Floor Opening
q
Window Opening
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Open Sided Floor
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Deck / balcony
q
Leading Edge
q
Scaffold Work
q
Mobile Lift Work
q
Ladder Work
q
Excavation Edge
q
Grade Drop-Off
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Other:________
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Fall
Arrest Harness:
Anchor points must be capable of withstanding 5000 pound shock
unless a deceleration device in use limits free fall to 2 feet in
which case a 3000 pound anchor point may be used.
Anchors
points are: _________________________________________
Configuration and placement sketch attached:
q
Yes
q
No
Manufacturer’s installation instructions attached?
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Yes
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No
Free fall
may not exceed 6'. A lower level may not be contacted during a
fall. Lifelines must be placed or protected to prevent
abrasion damage. Snap hooks may not be connected to each other, or
to loops in webbing.
Harness
manufacturer: ______________________________________
Manufacturer’s use and care instructions attached?
q
Yes
q
No
Additional Instructions: |
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Roof > 4/12 Pitch
q
Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Open Beam
q
Truss/Top Plate
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Scaffold Work
q
Mobile Lift Work
q
Ladder Work
q
Excavation Edge
q
Grade Drop-Off
q
Other:________
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Fall protection methods
Identified Fall hazards
above 10 feet
Check all that apply
|
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Fall
Restraint Harness:
Anchor points must be able to withstand 4 times the body weight with
tools of the heaviest person who will use the system. The system
must
always be rigged to prevent a free fall from the work surface.
Several alternate anchor points may be necessary to prevent free fall
from any location. If a horizontal catenary line is used, it will
be designed by a competent person who recognizes that a horizontal line
can multiply the force applied to the anchor.
Anchors
points are: _________________________________________
Configuration and placement sketch attached:
q
Yes
q
No
Manufacturer’s installation instructions attached?
q
Yes
q
No
Harness
manufacturer: ______________________________________
Manufacturer’s use and care instructions attached?
q
Yes
q
No
Additional Instructions:
|
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Roof > 4/12 Pitch
q
Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Scaffold Work
q
Mobile Lift Work
q
Excavation Edge
q
Grade Drop-Off
q
Other:________
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Warning
Line System:
A line made up of
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rope
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wire or
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chain
between 36" - 42" above the surface flagged at 6 foot intervals will be
attached to stanchions such that pulling on one section of chain will
not take up slack in the other sections. The stanchions must be
able to withstand a 16 pound force applied horizontally at 30" high. The
warning line will be erected at least 6 feet back from the fall hazard.
It will be set up so that a person entering will be directed to the work
zone and prevented from entering unprotected areas.
Configuration and placement sketch attached:
q
Yes
q
No
Additional Instructions:
|
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Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Other:________
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Safety
Monitor System:
A warning line will be erected a minimum of 6' back from the
roof or leading edge. Authorized employees working in the zone
between the fall hazard and the warning line will be monitored by a
competent person designated as safety monitor. The monitor
and the employees (maximum 8) will wear high visibility vests. The
monitor’s vest will be marked “Monitor". The monitor will be in
visual and voice range of employees in the control zone and have
no other duties except watching, warning and directing employees
regarding fall hazards. This system will not be used in adverse
weather conditions such as snow, rain, or high wind or after dark.
Monitor(s):
_________________________________________________
Control
Zone Employees:______________________________________
__________________________________________________________
Additional Instructions:
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Leading Edge
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Roof =< 4/12 Pitch
All other
uses prohibited per WAC 296-155-24521(1)
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Fall protection methods
Identified Fall hazards
above 10 feet
Check all that apply
|
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Hole/opening cover:
It must be able to support 2 X the weight of employees and equipment.
It will be secured to prevent accidental displacement. We will use
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hinges
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cleats nailed to the underside of the cover
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Nail or screw it in place. It will be marked "Cover" on top.
Our
covers will be made from: __________________________________
Additional Instructions:
|
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Skylight Opening
q
Roof Opening
q
Floor Opening
q
Other:________ |
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Catch
Platform:
Must be installed within 10' vertical of the work area. Must be as
wide as the fall distance (minimum 45”). Must have guardrails on
all open sides.
Additional Instructions: |
q
Roof > 4/12 Pitch
q
Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Open Beam
q
Truss/Top Plate
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Other:________
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Safety
Net:
Must be
installed within 30 feet vertical of the work surface and must extend
out from the outermost projection of the work surface:
Up to 5'
Fall = 8 Feet
Actual vertical fall distance: ____________
5' to 10'
Fall = 10 Feet
>
10' Fall = 13 Feet
Actual net width: _______________
A person falling into the net can't contact any
object below the net. The system must be tested or certified to
withstand a 400 pound object dropped from the highest work surface.
Mesh at any point must not exceed 36 square inches with the largest
opening being 6" side to side. Inspect weekly for mildew, wear or
damage and remove any objects in net as soon as possible.
Anchors
points are: _________________________________________
Configuration and placement sketch attached:
q
Yes q
No
Manufacturer’s installation instructions attached?
q
Yes
q
No
Additional Instructions:
|
q
Roof > 4/12 Pitch
q
Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Open Beam
q
Truss/Top Plate
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Scaffold Work
q
Mobile Lift Work
q
Ladder Work
q
Excavation Edge
q
Grade Drop-Off
q
Other:________ |
Fall protection methods
Identified Fall hazards
above 10 feet
Check all that apply
|
q
Positioning Belt:
A full body harness will be used with two lanyards attached to “D” rings
on each side of the employee’s waist. The employee will attach
both lanyards to an anchor point and be rigged to not be able to fall
more than 2 feet . The anchor must be able to sustain 2 times the
intended load or 3000 lbs whichever is greater. Snap hooks must
not be connected to each other or to loops in webbing.
Anchors
points are: _________________________________________
Configuration and placement sketch attached:
q
Yes
q
No
Manufacturer’s installation instructions attached?
q
Yes
q
No
Additional Instructions:
|
q
Roof > 4/12 Pitch
q
Open Beam
q
Truss/Top Plate
q
Window Opening
q
Ladder Work
q
Work from Wall
q
Other:_______ |
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Other
Fall Protection System:
Provide a description of how the system is to be assembled,
disassembled, operated, inspected and maintained including
specifications for materials to be used in its construction: |
q
Roof > 4/12 Pitch
q
Roof =< 4/12 Pitch
q
Skylight Opening
q
Roof Opening
q
Floor Opening
q
Open Beam
q
Truss/Top Plate
q
Window Opening
q
Open Sided Floor
q
Deck / Balcony
q
Leading Edge
q
Scaffold Work
q
Mobile Lift Work
q
Ladder Work
q
Excavation Edge
q
Grade Drop-Off
q
Other:________
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Note:
Fall
protection systems will be assembled and maintained according to
manufacturer's instructions when using a manufactured system.
q
A
copy of those instructions are available on site for reference.
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Our fall protection systems will meet OSHA regulations |
Protection Against Overhead Hazards
When employees are working at elevation, we will
provide the following protection(s) for employees working below:
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Require persons to wear hard hats
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Screens on Guardrails
q
Overhead
Hazard Signs
q
Toe
Boards on Guardrails
q
Debris
Nets
q
Barricade to Control Access
q
Other
_____________________________________________________________________
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