test guardrail cond 3

Filled for Category: Site Specific Fall Protection Plan version 3 (Form)
Site: Form Creator | Employer: We the Safe Inc.
Download PDF Send Email Generate QR Code for Worker Signing
Template Updated about 1 month ago

Creation details

Disclaimer:
This QRsafety.com Smart Form is a series of questions that should be answered prior to working at heights. The questions may not identify every hazard for your task and location. The form is to be completed by a qualified person that can identify all hazards and add any that are missing.
This Smart Form has fields that will be hidden if they are not relevant to the work, as determined by your hazard assessment answers.
The completed Site Specific Fall Protection plan may be a part of the total solution however is not to be the only part of it. Users use it at their own risk.
Date:
N/A
Creators contact info - add additional rows if needed:
No data entered

Workplace location/ contact details

Location:
No data entered
Location cont.:
No data entered
Supervisor info - add additional rows if needed:
No data entered

Work area details

What type of structure/ work area? :
N/A
What location is the work taking place (level/ side etc.)?:
N/A
What type of work (ex. window washing)?:
N/A

Hazards (basic) with standard controls

Definition Hazard:
Anything that could harm a worker or the public. Think of your work and location - what could happen to hurt workers or public
Definition Control:
Steps/ actions taken to eliminate or decrease the risk of the hazards identified above. NOTE - best practice and regulations require controls to be chosen following a hierarchy with elimination being the first.
Can a worker fall to lower surface from leading edges, roof, shafts, openings, doorways etc..?:
No selection made
Available options:
Yes No
Is it possible to drop tools/ materials or have workers/ public enter your work area and be exposed to a fall hazard?:
No selection made
Available options:
Yes No
Are there power lines near your work area?:
No selection made
Available options:
Yes No

Hazards (task Specific) with control checklist added when chosen

Is there a fall hazard during access to the work area? - example: needing to climb a roof to connect to anchor:
No selection made
Available options:
Yes No
Are there floor openings that you could fall in?:
No selection made
Available options:
Yes No
Is the work surface a steep slope (8/12 +)?:
No selection made
Available options:
Yes No
Is the lower surface less than 18’ below anchor point?:
No selection made
Available options:
Yes No
Are there any other hazards?:
N/A

Hazards (ladders and work platforms) with control checklist when chosen

Are you working from a ladder?:
No selection made
Available options:
Yes No
Are you working from a mobile elevated work platform?:
No selection made
Available options:
Yes No
Are you working from a scaffold?:
No selection made
Available options:
Yes No
Are you working from a swing stage?:
No selection made
Available options:
Yes No
Are you working from a bosuns chair?:
No selection made
Available options:
Yes No
Are you using rope access?:
No selection made
Available options:
Yes No
Are there any other work platforms you are using?:
N/A

Controls - Personal Fall Protection system and administrative

Are you to able work in an area with guardrails controlling fall hazards? note - swing stage guardrails require a back up fall arrest system :
Selected:
Yes, I will also use other controls
Available options were:
Yes – 100% of time including access to the work area Yes, I will also use other controls No
Guardrails not 100% - why:
N/A
Are you able to work in fall restraint – a tight line stops you from falling over the edge?:
No selection made
Available options:
Yes – 100% of the time restraint and/ or guardrails Yes, but not all the time No

Equipment list and system step by step set up- will be empty when not applicable

Components needed:
Based on the controls - the following components/ permits and/or tools will be part of your fall protection systems.
Step by step:
Do not proceed until you have reviewed and understand the manufacturer instructions. These step by step are in additional to them.
Fall Protection anchor item(s) needed:
0 selecteds of 6 items
Cast in web anchor strap
Choked around structure web or cable anchor strap
Bolt down anchor
Beam slider
Door/window jamb anchor
Re-usable concrete anchor
Are there any other anchors you will be using?:
No selection made
Available options:
Yes No
Harness options needed:
0 selecteds of 6 items
Basic single D ring - class A
Side D rings for work positioning - class P
Shoulder D rings for confined space - class E
Site saddle for extended work positioning
Sternum D ring - class L
Arc resistant - class R
Will you be using a rope grab?:
No selection made
Available options:
Yes No
Will you be using a vertical lifeline?:
No selection made
Available options:
Yes No
Will you be using an energy absorbing lanyard?:
No selection made
Available options:
Yes No
Will you be using a horizontal lifeline?:
No selection made
Available options:
Yes No
Will you be using work positioning?:
No selection made
Available options:
Yes No
Will you be using a self retracting device (SRL/ SRD/ YOYO)?:
No selection made
Available options:
Yes No

Photos - add photos that will help users understand the hazards and controls

Do you want to add any photos:
No selection made
Available options:
Yes No

Drawings - add any that will help users understand the hazards and controls

Do you want to upload any files:
No selection made
Available options:
Yes No

Inspections

Pre-use and routine inspections:
The checked items will be inspected following the manufacturer instructions and at intervals checked to confirm set up is correct.
Guardrail inspections - before use:
0 selecteds of 5 items
No gaps large enough to pass through
Top rail 40-44" above work surface
Posts securing rails on narrow side
125 pounds strength horizontally - do not pass over edge with force
If manufactured system - consult instructions
These components will be inspected before use:
0 selecteds of 8 items
Anchorage (the structure)
Anchor (connects to structure)
Lifeline
Self retracting device
Rope Grab
Lanyard
Carabiners/ connectors
Tool tethers
Also - After a break these components will be inspected.:
0 selecteds of 8 items
Anchorage connection to anchor
Lifeline connection to anchorage
Self retracting device connection to anchorage
Rope grab connection to lifeline
Buddy check on harness
Lanyard connection
Exclusion zone set up
Guardrail system

Rescue

Rescue types:
The following rescue techniques will be used in a hierarchy approach with self rescue being the first choice.
Fall Restraint rescue:
In a fall restraint system you cannot fall therefore rescue will not require work at heights. Follow standard injury/ first aid procedures.
Administrative controls - rescue:
Administrative controls do not allow a worker to get within 6.5' of a fall hazard. Rescue will be standard injury/ first aid procedures.
Rescue types:
By choosing a scenario, the step by step instructions will be added to this plan.
Choose as many as needed.
They are listed in a hierarchy or difficulty.
We will use Worker self rescue first:
No selection made
Available options:
Yes No
We will use Worker assisted rescue when self rescue cannot be used:
No selection made
Available options:
Yes No
We will use DEP box rescue - only choose if a DEP box and crane is on site - when self or assisted rescue are not possible:
No selection made
Available options:
Yes No
We will use MEWP (scissor or boom) rescue when one is available and worker is conscious:
No selection made
Available options:
Yes No
We will use a rope rescue system - only choose if there is a system available:
No selection made
Available options:
Yes No
Emergency services rescue (fire department) :
No selection made
Available options:
Yes No

Notes from any section

Add any additional notes in this area:
N/A

Workers sign off

Signatures:
Choose the workers who will review this Site Specific Fall Protection Plan. A copy of this completed from will be added to each workers profile for future reference.
Worker Sign-offs:

No workers assigned to this form.

Edit this Form