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Fall Protection Work Plan
Employees must review and adhere to the requirements of this fall protection work plan for the duration of work activities.
Job Name
Date
MM slash DD slash YYYY
Job Location Description
Task(s) to Be Completed
Competent Person(s)
Fall Hazards
Select all existing or potential hazards associated with work task(s) where a fall would exceed 4’.
Leading Edge(s)
Floor Openings
Scaffold
Stairway(s)
MEWP (scissor / boom)
Wall Openings
Hazardous Process / Equipment
Ladder(s)
Shaft Openings
Other
If "Other", Specify:
Fall hazards photo
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Max. file size: 100 MB, Max. files: 10.
Fall Protection System to Be Used
Select all components of the Personal Fall Arrest or Personal Fall Restraint System to be used.
Full Body Harness
Self-Retracting Lifeline
Shock Absorbing Lanyard
Positioning Lanyard
Guardrail System
Safety Monitor
Horizontal Lifeline
Rope Grab
Safety Nets
Restraint / Warning Line
Lifeline / Static Line
MEWP (scissor / boom)
Scaffold with Guardrail
Other (Specify):
If "Other", Specify:
Inspection & Maintenance of Fall Protection System
Describe the procedures for the inspection and maintenance of the fall protection system to be used.
Assembly & Disassembly of Fall Protection System
Describe the procedures for the assembly and disassembly of the fall protection system to be used.
Photo for Assembly & Disassembly of Fall Protection System
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Select files
Max. file size: 100 MB, Max. files: 10.
Handling, Storage and Securing of Tools and Materials
Describe the method for handling, storing and security of tools, equipment, and materials.
Method(s) of Overhead Protection
Select all methods of overhead protection for workers who may be in or pass through the area below the worksite.
Delineation / Barricading
Safety Helmet
Warning Signs
Tool Lanyards
Toeboards
Other
If "Other", Specify:
Fallen Worker Rescue Plan
In the event of a fall from height, the fallen worker will first attempt to perform self-rescue. The supervisor will immediately alert HBI rescue and first aid teams. If the rescue team cannot perform a
rescue within 3 minutes
the Jobsite Contact and Emergency Services are to be called immediately.
Emergency Phone Number
or
Rescue Team:
First Aid Team:
Jobsite Contact Name:
Jobsite Contact Number:
Jobsite Contact Company:
Rescue Equipment
Select all equipment that will be needed to assist in the aid and rescue of a fallen worker.
Ladder
MEWP (scissor/boom)
Rescue Rope
Rescue Pole
Suspension Trauma Straps
Alternative Lifting & Lowering Device
First Aid Kit
AED
Stretcher
Life Ring
Other
If "Other", specify:
Location of Equipment:
Communication or Method of Contact
Select all communication methods that will be used between the fallen worker and rescue team.
Direct Voice
Mobile Phone / Number:
Radio / Channel:
Other
If "Other", Specify:
Mobile Phone / Number:
Radio / Channel:
Rescue Procedures
Pre-Work Tasks:
Identify rescue & first aid team(s).
Inspect work area.
Identify additional access / anchor points.
Inspect and stage rescue equipment.
Review rescue plan with crew.
Coordinate rescue plan with jobsite contact.
Response Procedures:
Make medical assessment of worker.
If possible, have worker perform self-rescue.
If unable, notify rescue & first aid team(s).
Notify jobsite contact & call 911 or ________.
Assist emergency responders.
Notify Hudson Bay Insulation safety team.
Special Cosideration & Coordination
Describe in detail any special considerations or coordination that will aid in the rescue of a fallen worker, (i.e., anchor points, landing area, rescue obstructions or hazards, working alone, weather, etc.)
Employee Acknowledgment of Fall Protection Training
All employees are to adhere to the Fall Protection procedures that are set forth in the HBIC Safety & Risk Management Plan. All employees shall have been trained by a qualified competent person; the training shall consist of a review of the fall protection work plan and the proper use of fall protection equipment before work is to begin. Copies of this form are to be turned into the HBIC Safety Department and maintained at the jobsite.
Name:
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Name:
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Approvals
Fall Protection Work Plan Completed By:
First
Last
Signature
Foreman Name
First
Last
Foreman Signature
Date
MM slash DD slash YYYY
Crewmember 1 Name:
First
Last
Crewmember 1 Signature
Crewmember 1 - I agree the above name and signature are my own
Yes
Crewmember 2 Name:
First
Last
Crewmember 2 Signature
Crewmember 2 - I agree the above name and signature are my own
Yes
Crewmember 3 Name:
First
Last
Crewmember 3 Signature
Crewmember 3 - I agree the above name and signature are my own
Yes
Crewmember 4 Name:
First
Last
Crewmember 4 Signature
Crewmember 4 - I agree the above name and signature are my own
Yes
Crewmember 5 Name:
First
Last
Crewmember 5 Signature
Crewmember 5 - I agree the above name and signature are my own
Yes
Crewmember 6 Name:
First
Last
Crewmember 6 Signature
Crewmember 6 - I agree the above name and signature are my own
Yes
Crewmember 7 Name:
First
Last
Crewmember 7 Signature
Crewmember 7 - I agree the above name and signature are my own
Yes
Crewmember 8 Name:
First
Last
Crewmember 8 Signature
Crewmember 8 - I agree the above name and signature are my own
Yes
Crewmember 9 Name:
First
Last
Crewmember 9 Signature
Crewmember 9 - I agree the above name and signature are my own
Yes
Crewmember 10 Name:
First
Last
Crewmember 10 Signature
Crewmember 10 - I agree the above name and signature are my own
Yes
Crewmember 11 Name:
First
Last
Crewmember 11 Signature
Crewmember 11 - I agree the above name and signature are my own
Yes
Crewmember 12 Name:
First
Last
Crewmember 12 Signature
Crewmember 12 - I agree the above name and signature are my own
Yes
Crewmember 13 Name:
First
Last
Crewmember 13 Signature
Crewmember 13 - I agree the above name and signature are my own
Yes
Crewmember 14 Name:
First
Last
Crewmember 14 Signature
Crewmember 14 - I agree the above name and signature are my own
Yes
Crewmember 15 Name:
First
Last
Crewmember 15 Signature
Crewmember 15 - I agree the above name and signature are my own
Yes
Submitted To:
First
Last
Date
MM slash DD slash YYYY
Approved By:
First
Last
Date
MM slash DD slash YYYY
Additional Email 1
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Additional Email 2
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