Fall Protection Form

USER
MODEL
SERIAL
DATE OF MANUFACTURE

MonthDayYear
Date
TYPE OF LANYARD
Flat web with pouch EA Y-lanyard

Tubular web-elastic pouch EA Y-lanyard
Cable web with pouch EA Y-lanyard
PCL
Name of Competent Inspector
Connectors
Broken, Missing, or Loose Stitching Termination (stitch or splice or swage)
Date

MonthDayYear
Date
Label
Termination
Integrity of Cover Signs of Deployment Signs of Damage

Function of Connector Locking Gate Body of Hook or Rivets Corrosion
NOTES
Shock Pack
Paint Damage
Webbing
Signs of Damage
Signs of Deployment
CONNECTORS & D-RINGS
Body of Hook or Rivets
Label
Nicks
Shock Pack
Termination
Legible Label Appropriate ANSI/CSA/OSHA Markings
Legible Label
Deterioration - Eaten or worn away by chemicals
Date of First Use

MonthDayYear
Date
Appropriate ANSICSAOSHA Markings
Pitting A small indentation in a surface
Webbing
Nicks - A shallow notch, cut, or indentation on an edge or surface
Should be Empty:

PCL