Fall Protection Equipment Inspection Form
Do you understand that it is your duty to complete this form correctly with new photographs each month and failure to do so can result with disciplinary action
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Yes
No
Name of Operative
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First Name
Last Name
Date
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Month
-
Day
Year
Date
Manager
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Please Select
Russ Day
Kane Carr
Dylan Forrett
Oliver Knight
Andrew Collins
Craig Wilson
Gary Forster
Chris Dunbar
Harness
Harness - Is the harness manufactuers label present and eligable?
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Yes
No - Report defect to Manager and Member of HSE Team
Harness Model
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Harness Seriel Number
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Harness Manufactuer Date
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Month
-
Day
Year
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?
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Yes
No - Report defect to Manager and Member of HSE Team
Harness - Are D Rings & Buckles free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
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Yes
No - Report defect to Manager and Member of HSE Team
Harness - Is the back pad present, free from damage and does it have a reflective strip.
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Yes
No - Report defect to Manager and Member of HSE Team
Harness - Does the harness have a coloured tag?
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Yes
No - Report missing tag to Manager and Member of HSE Team
Harness - What Colour is the tag?
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Harness - Photograph of colored tag.
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Harness Comments - Please note condition of harness and any issues with Harness.
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Harness - Overall Pass or Fail
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Pass
Fail - Report defect to Manager and Member of HSE Team
Pole Belt
Pole Belt - Is the manufactuers label present and eligable?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Pole Belt Model:
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Pole Belt Seriel Number
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Pole Belt Manufactuer Date
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-
Month
-
Day
Year
Date
Pole Belt - Are D Rings & Buckles free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Does the pole belt have a coloured tag?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Pole Belt - What Colour is tag?
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Pole Belt - Photograph of coloured tag.
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Pole Belt - Overall Pass or Fail
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Pass
Fail - Report defect to Manager and Member of HSE Team
NA
Comments - Please condition of pole belt note any issues with Pole Belt. (Add N/A if not applicable).
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Fall Arrest Lanyard
Fall Arrest Lanyard - Is the manufactuers label present and eligable?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Arrest Lanyard Model
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Fall Arrest Lanyard Seriel Number
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Fall Arrest Lanyard Manufactuer Date
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-
Month
-
Day
Year
Date
Fall Arrest Lanyard - 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?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Arrest Lanyard - Are D connectors free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Arrest Lanyard - Is the shock obsorber free from cuts,tears,abrasions or is it deployed stretched or elongated?
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Yes
No - Report defect to Manager and Member of HSE Team
NA - MEWP (Fall Restraint) Lanyard does not have shock obsorber.
NA
Fall Arrest Lanyard - Does the lanyard have a coloured tag?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Arrest Lanyard - What Colour is the tag?
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Fall Arrest Lanyard - Photograph of colored tag.
*
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Fall Arrest Lanyard - Overall Pass or Fail
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Pass
Fail - Report defect to Manager and Member of HSE Team
NA
Fall Arrest Lanyard - Comments - Please note condition of lanyard and any issues with Lanyard. (Add N/A if not applicable)
*
Fall Restraint Lanyard (Mewp)
Fall Restraint Lanyard - Is the manufactuers label present and eligable?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Restraint Lanyard Model (Type NA if not applicable)
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Fall Restraint Lanyard Seriel Number (Type NA if not applicable)
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Fall Restraint Lanyard Manufactuer Date (Type NA if not applicable)
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Month
-
Day
Year
Date
Fall Restraint Lanyard - 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?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Restraint Lanyard - Are D connectors free from Cracks, bends, Corrosion, sharp edges, poor functionality or damage?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Restraint Lanyard - Does the lanyard have a coloured tag?
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Yes
No - Report defect to Manager and Member of HSE Team
NA
Fall Restraint Lanyard - What Colour is the tag? (Type NA if not applicable)
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Fall Restraint Lanyard - Photograph of colored tag.
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Fall Restraint Lanyard - Overall Pass or Fail
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Pass
Fail - Report defect to Manager and Member of HSE Team
NA
Fall Restraint Lanyard - Comments - Please note condition of lanyard and any issues with Lanyard. (Add N/A if not applicable)
*
Helmet
Helmet Manufactuer Date
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-
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?
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Yes
No - Report defect to Manager and Member of HSE Team
Overall Pass or Fail
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Pass
Fail - Report defect to Manager and Member of HSE Team
Comments - Please note condition and any issues with helmet .
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Sign Off
Is the operative missing any kit or is the operative unsure of what kit is required?
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Operative is missing kit / unsure of what is required , Manager and HSE team to be notified.
Operative has the correct kit
Has any item of kit failed the inspections? (If yes remove from service and notify Manager and HSE team to arrange replacment).
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Yes
No
If any kit has failed please state what kit and reason for failure. (Note NA if not applicable).
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If Harness has been withdrawn from service, note seriel number below. (Note NA if not applicable).
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If Fall Arrest Lanyard has been withdrawn from service, note seriel number below. (Note NA if not applicable).
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If Fall Restraint Lanyard (MEWP) has been withdrawn from service, note seriel number below. (Note NA if not applicable).
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If pole belt has been withdrawn from service, note seriel number below. (Note NA if not applicable).
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Is all PPE the same equipment that was issued to the operative by Map Group UK? If no contact Manager and HSE team
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Yes
No
Comments
Is this inspection carried out by an operative on their own kit or by a Safety Advisor/Supervisor/ Manager?
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Engineer on own kit
Safety Advisor/Supervisor /Manager
Name of kit Inspector
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First Name
Last Name
Sign Name
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Submit
If any kit has failed please state what kit and reason for failure. (Note NA if not applicable).
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Should be Empty: