Fall Protection Task Plan

FALL PROTECTION TASK PLAN
Project*
Company*
Date*

MonthDayYear
Date
Engineering ControlsFall Restraint SystemsPersonal Fall Protection
The Fall Protection Permit is for (specific location)*
Prepared By*
Implemented By*
Monitored By*
Approved By*
Specific Task Description*
HarnessLanyardRetractablePosition HookHole CoversBarricadeYellow Caution TapeRed Danger TapeGuard RailingHorizontal SystemVertical SystemSafety Net System*Controlled Access Zone*Safety Monitored System
*Notes systems which require a specific written fall protection plan and approval
YesNo
One man use (5,000 lbs)Two man use (10,000 lbs.)
Identify means for protection here, if not listed
Explain how Fall Protection System will be used*
YesNo
Instructed By*
Rescue Procedure in the event worker falls*
A copy of this fall protection permit, once approved, shall be reviewed during PSI and added to this fall protection plan
Sign off that the fall task plan on the opposite side has been reviewed with me or reviewed by me.
*Each member of the crew to print and sign below that this fall task plan has been reviewed*
Worker #1 Name

First NameLast Name
Worker #1 Signature
Worker #2 Name

First NameLast Name
Worker #2 Signature
Worker #3 Name

First NameLast Name
Worker #3 Signature
Worker #4 Name

First NameLast Name
Worker #4 Signature
Worker #5 Name

First NameLast Name
Worker #5 Signature
Worker #6 Name

First NameLast Name
Worker #6 Signature
Worker #7 Name

First NameLast Name
Worker #7 Signature
Worker #8 Name

First NameLast Name
Worker #8 Signature
Worker #9 Name

First NameLast Name
Worker #9 Signature
Worker #10 Name

First NameLast Name
Worker #10 Signature
Should be Empty:

FALL PROTECTION TASK PLAN

*Notes systems which require a specific written fall protection plan and approval

*Each member of the crew to print and sign below that this fall task plan has been reviewed*

Each member of the crew to print and sign below that this fall task plan has been reviewed