Site Specific Fall Protection Plan version 3 - Instance 874

Filled for Category: Site Specific Fall Protection Plan version 3 (Form)
Site: Form Creator | Employer: Panorama West Group
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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:
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Creators contact info - add additional rows if needed:
No data entered

Workplace location/ contact details

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

Work area details

What type of structure/ work area? :
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What location is the work taking place (level/ side etc.)?:
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What type of work (ex. window washing)?:
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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 :
No selection made
Available options:
Yes – 100% of time including access to the work area Yes, I will also use other controls No

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

Step by step:
Do not proceed until you have reviewed and understand the manufacturer instructions. These step by step are in additional to them.

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.

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
Notice - WSBC and emergency services:
NOTE 1– prior to considering emergency services your only rescue provider an assessment following requirements in WSBC Guidelines 14.3(1) must be completed and emergency services notified.
Note 2 - When doing short duration suspended work you should also consider the “Notice of Rescue Service for Short-term Work” found in section 4.13 of the WSBC guidelines - https://www.worksafebc.com/en/law-policy/occupational-health-safety/searchable-ohs-regulation/ohs-guidelines/guidelines-part-04#SectionNumber:G4.13_1

Notes from any section

Add any additional notes in this area:
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Workers sign off

Signatures:
Supervisor signs to confirm it has been reviewed by workers - attach an additional sign off sheet if needed
Signature:
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