Monthly Fall Protection Equipment Inspection Form
Name of Operative
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Manager
Harness
Harness Model
Harness Seriel Number
Photograph Of Harness Seriel Number
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Harness Manufactuer Date
-
Month
-
Day
Year
Date
Is Harness Within 5 Years of Manufactuer Date ?
Yes
No
Comments on Manufactuers date
Is the harness webbing & Stitching free from Cuts, Tears, holes, burns,frays,nots,UV damage, grease,grime,mold,paint,discolouration,heat damage,permanent markings abrasions?
Yes
No
Comments on Webbing & stitching.
Photograph Of Defective Webbing or stitching.
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Are D Rings & Buckles free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
Yes
No
Comments
Photograph of defective D Ring or buckle.
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Is the back pad present, free from damage and does it have a reflective strip.
Yes
No
Comments
Photograph of defective back pad.
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Does the harness have a coloured tag?
Yes
No
What Colour is the tag?
Comments
Photograph of colored tag.
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Is the manufactuers label present and eligable?
Yes
No
Photograph of manufactuers lable.
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Overall Pass or Fail
Yes
No
Pole Belt
Pole Belt Model:
Pole Belt Seriel Number
Photograph Of Pole Belt Seriel Number
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Pole Belt Manufactuer Date
-
Month
-
Day
Year
Date
Is Pole Belt Within 5 Years of Manufactuer Date ?
Yes
No
Comments on Webbing & stitching.
Photograph Of Defective Webbing or stitching.
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Are D Rings & Buckles free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
Yes
No
Comments
Photograph of defective D-Ring/Hooks.
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Does the harness have a coloured tag?
Yes
No
Photograph of coloured tag.
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Is the manufactuers label present and eligable?
Yes
No
Photograph of manufactuers lable.
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Overall Pass or Fail
Yes
No
Lanyard
Lanyard Model
Lanyard Seriel Number
Photograph Of Lanyard Seriel Number
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Lanyard Manufactuer Date
-
Month
-
Day
Year
Date
Is Lanyard Within 5 Years of Manufactuer Date ?
Yes
No
Comments on Manufactuers date
Is the lanyard webbing & Stitching free from Cuts, Tears, holes, burns,frays,nots,UV damage, grease,grime,mold,paint,discolouration,heat damage,permanent markings abrasions?
Yes
No
Comments on Webbing & stitching.
Photograph Of Defective Webbing or stitching.
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Are D connectors free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
Yes
No
Comments
Photograph of defective connector.
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Is the shock obsorber free from cuts,tears,abrasions oris it deployed stretched or elongated?
Yes
No
Comments on Shock obsorber.
Photograph of defective shock obsorber.
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Does the lanyard have a coloured tag?
Yes
No
What Colour is the tag?
Comments
Photograph of colored tag.
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Is the manufactuers label present and eligable?
Yes
No
Photograph of manufactuers lable.
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Overall Pass or Fail
Pass
Fail
Climbing Helmet
Helmet Manufactuer Date
-
Month
-
Day
Year
Date
Is the helmet free from abrasions, cracks, dents markings. Is the inner free from cuts, frayed webbing. Is the chin strap fitted and does the helmet have any missing pieces?
Yes
No
Photograph of faulty helmet
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Overall Pass or Fail
Pass
Fail
Hoist - Fall Restraint Lanyard
Fall Restraint (Hoist) Lanyard Model
Fall Restraint (Hoist) Lanyard Seriel Number
Photograph Of Fall Restraint (Hoist) Lanyard Seriel Number
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Fall Restraint (Hoist) Lanyard Manufactuer Date
-
Month
-
Day
Year
Date
Is Lanyard Within 5 Years of Manufactuer Date?
Yes
No
Is the lanyard webbing & Stitching free from Cuts, Tears, holes, burns,frays,nots,UV damage, grease,grime,mold,paint,discolouration,heat damage,permanent markings abrasions?
Yes
No
Comments on Webbing & Stitching.
Photograph of any Lanyard defects.
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Does the lanyard have a coloured tag?
Yes
No
What Colour is the tag?
Photograph of colored tag.
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Is the manufactuers label present and eligable?
Yes
No
Photograph of manufactuers lable.
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Overall Pass or Fail
Pass
Fail
Sign Off
Has any item of kit failed the inspections? (If so remove from service and arrange replacment).
Yes
No
If any kit has failed please state what kit and reason for failure.
Is all PPE the same equipment that was issued to you by Map Group UK?
Yes
No
Comments
Is this inspection carried out by an engineer on their own kit or by a Safety Advisor/Supervisor/ Manager?
Engineer on own kit
Safety Advisor/Supervisor /Manager
Does the operative have any confined space equipment on their vehicle, e.g., winch, tripod, breathing aparatus, 2 way radios? If yes please contact HSEQ department.
Yes
No
Type Name of kit Inspector
First Name
Last Name
Sign Name
Submit
Should be Empty: