Val Construction Fall Protection Plan

Site Fall Protection Plan
Work Site*
Date

MonthDayYear
Date
Completed By*

First NameLast Name
Your Email
example@example.com
- Workers must review and sign this fall protection work plan prior to starting work. Workers must understand this plan and be trained in fall protection and the systems and equipment that will be used.
- This Fall Protection Work Plan must be posted at the worksite for the duration of work activities.
Mobile elevating work platformsExcavations/trenchesFloor openingsWall openingsSkylight openingsRoof openingsElevator shaftLadders (fixed or portable)ScaffoldStairwaysSloped RoofSwing fallHazardous process/equipmentDebris/objects falling to lower levelSharp edgesReinforcing steel installationOther
Enter Pitch of Roof
2. Describe the fall hazard(s) details.
Guardrail systemCovers (holes and openings)Appropriate anchors for systems usedPersonal fall arrest systemPersonal fall restraint systemPositioning device systemScaffold with guardrailScissor liftAerial liftVertical lifeline and rope grabControl Zone / Warning lineOther
4. Describe procedures for assembly, maintenance, inspection, disassembly of fall protection system to be used.
5. Describe procedures for handling, storage, securing tools and materials at height.
BarricadingHard hats requiredCatch netWarning signsTool beltsTool lanyardsToeboards/screens on scaffoldsToeboards/covers on floor openingsScreens on guardrailsSecure large toolsOther
6. Detail Rescue Plan for prompt safe removal of fallen workers
Self RescueUse site Man LiftAccess via Stairs/ElevatorAccess with LaddersAccess via ScaffoldOther
Site First Aid
Call 911 in addition to following above rescue plan
Full body harnessVertical lifelineHorizontal lifelineLanyardChokerCarabinerRope grabPersonal shock absorberConnecting devicesAnchorage pointsOther
Identify Connecting Devices
Identify Anchorage Points
8. Calculate the Minimum Fall Clearance (ft)

Fall clearance is the minimum vertical distance needed between the anchor point and a lower level (this can be the ground or lower obstruction) with a safety factor to prevent the worker from hitting the lower level in a fall.
Distance from anchor to ground, lower level or obstruction
Length of Lanyard or Free Fall Distance for self-retracting lifeline
When using a retractable lifeline, the distance is calculated from the point where the retractable attaches to the back D-ring of the Worker's Harness
Maximum allowable deceleration distance
Worker's Height
Other component (if applicable)
When using other components such as cross-arm anchorage connector, please include the length of such components here.
Safety Factor
Minimum Fall Clearance (ft)
The calculated minimum fall clearance is greater than the distance between the anchor point and the lower level.

Review and recalculate before continuing.
Type option 1Type option 2
The calculated minimum fall clearance is less than the distance between the anchor point and the lower level.

This will help protect you if you fall. Stay diligent and work safe, even small falls can cause injury.
9. Employee(s) trained to work under this plan
How many employees are trained to work under this plan?
1. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
2. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
3. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
4. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
5. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
6. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
7. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
8. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
9. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
10. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
11. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
12. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
13. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
14. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
15. Employee Name

First NameLast Name
Employee Signature

Clear
Date

MonthDayYear
Date
Name of Competent Person reviewing this plan with employee(s) above

First NameLast Name
Title
Name of lead worker or supervisor

First NameLast Name
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

Site Fall Protection Plan

Call 911 in addition to following above rescue plan

8. Calculate the Minimum Fall Clearance (ft)

9. Employee(s) trained to work under this plan