Written Site-Specific Fall Protection Plan Template - Workers' Safety And Compensation Commission, Nanavut, Canada

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Written Site-specific
Fall Protection Plan
Planning plays a key role in protecting workers from fall hazards. This fall protection plan template can assist
the planning process. Employers should ensure that fall protection plans are designed to address site-
specific conditions and comply with Safety Acts and General Safety Regulations.
Site address:
Start date:
Site description:
Employer:
Work area:
Tasks:
Site-specific fall hazards
(see diagram on page 2 for more details)
Max. height (peak):
Max. height (eaves):
Max. height (other):
Roof slope(s), if applicable:
Proximity to high voltage power lines:
Ground cover/hazards:
Other/comments:
Type of fall protection you will use
(see definitions on page 3)
Fall restraint
Fall arrest
Temporary guardrail system
Equipment inspection
Item
Comment/defect
Item
Comment/defect
Full body harness
Anchors
Vertical lifelines
Ladders
Lanyards
Ladder hoist
Rope grabs
Toeboards
page 1 of 4
WRITTEN SITE-SPECIFIC FALL PROTECTION PLAN ADAPTED WITH PERMISSION –09.2014– FROM

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