• Ensure a written worksite specific fall protection plan is in place
• Ensure that a fall protection system is being used
• Ensure that guardrails are used when practicable
• Ensure a fall restraint system is in place when applicable
• If a fall restraint system cannot be used, ensure a fall arrest system is in place
• Provide appropriate control zone procedures if the above are not appropriate
• Ensure supervisors and workers are trained
• Ensure all equipment is safe, maintained, inspected and used correctly
• Investigate any anomalies in the system to make recommendations so that such anomalies will not happen again
• Update the program as needed
• Follow up on our program

• Ensure the program is prepared for each site
• Ensure the program is being implemented
• Inspect the program as it is used
• Review the program
• Investigate any anomalies and make recommendations to prevent reoccurrence
• Investigate all workers reports of anomalies to the system
• Keep a log of all workers trained for the fall protection program and topics that were covered before they work in the fall protected area
• Ensure all workers have a copy of the fall protection program
• Inspect, maintain, and use the equipment in the recommended methods
• Ensure that all workers are provided with the appropriate equipment
• Observe workers, work practices and site operations and correct when necessary

• Know the fall protection plan
• Follow the procedures as trained
• Inspect equipment
• Maintain equipment
• Report any anomalies to the supervisors
• Ensure the equipment is used as the manufacturer recommends
• Inspect the program
• It is a condition of employment that all managers, supervisors, and workers comply with the company safety policy and safety programs

Company Name and Address:
We at ______________ believe that our employees are very important to us. Fall Protection is an important aspect of our program to insure that people who work for us can continue to live safe and healthy lives. We at ______________ require all employees who work at heights above 10 feet and over to be protected from falling. In some cases, we will also implement fall protection at a lesser height if there is a danger or hazard in the area below. A written fall protection plan will be developed and implemented when a fall hazard of 25 feet or more exists or when a safety monitor and control zone is required.

The intent of the plan is to:

• Help prevent falls
• Assist workers and supervisors to identify the fall hazards of the site before work begins at heights.
• Assist in the selection of an appropriate fall protection system(s)
• Assist in rescue procedures for someone if a fall should occur

It is our company policy that all managers, supervisors and workers comply with the fall protection guidelines we have established. We have several checklists to help our supervisors and workers in identifying problem areas on the site. These checklists will be of much help when our supervisors are developing the site-specific program. We have outlined some specific responsibilities for ourselves (the employer), our supervisors and our workers as follows:

Signature of Management and Date

Company:
Address:
Phone:
Date:
Project:
Location:
Phone:
Date:
Supervisor:
Site Safety Representative:
Job Description and Type of Work (circle one):
New      Alterations      Demolition      Maintenance      Repair
Specific Work Area:
A brief description of the type of work being done:

Is a control zone used (circle one):     Yes       No
If yes, where:
Is the control zone marked (circle one):     Yes       No
If yes, how:
What is the set-back distance of the control zone area (circle one):    Meters        Feet

The Safety Monitor
Name of Safety Monitor:
Safety Monitor Training:
Date Trained:
Number of workers to be monitored:
Journeyman:
Apprentices:

All the following Workers have been trained in the Safety monitor system:
Date: 
1.
2.
3.
4.
5.
6.
7.
8.

Describe the type of work being done:

List the fall hazards:

Draw a diagram of the control zone:

Describe the type of fall protection system to be used:

Other considerations:

Describe the type of work being done in other fall hazard areas:

List the fall hazards:

Draw a diagram, if necessary:

Describe the type of fall protection system to be used:

Other considerations:

In detail, describe the procedure to be followed if someone is to be rescued after a fall occurs:

Other concerns or considerations:

• Hazard Identification
• Scaffold Work
• Lock Out
• Walls
• Floor Openings
• Edge of Slab
• Electrical Hazards
• Other Trades
• Manholes
• Shafts
• Doors
• Tripping Hazards
• Drop Off Points
• Fly Forms
• Swing Stages
• Excavations
• Crane Operations
• Work Access Above
• Walkways Above

Type of Fall Protection Name:

• Guardrails
• Toe Boards
• Horizontal Lifelines
• Vertical Lifelines
• Harness and Lanyard
• Belt and Lanyard
• Warning Lines
• Cover Over Holes
• Wire Rope Lifelines
• Fiber Rope Lifelines
• Robe Grabs
• Fall Arrest Blocks
• Tie Backs
• Safety Nets
• Canopies

Describe in detail all work procedures including hazard identification, assembly, maintenance, use, disassembly, and inspection of the equipment, system and/or area. Ensure all required equipment is provided, identified, inspected and put in a log book before use.

Equipment Log

All workers who will be exposed to fall hazards are informed of those hazards and are instructed in the fall protection system to be used and the procedures to be followed. All contents of this program have been conveyed to the workers. All necessary equipment has been provided.

Site Superintendent:
Signature:
Print Name:
Date:
Site Safety Representative:
Signature:
Print Name:
Date: