Written Site-Specific Fall Protection Plan Template - Workers' Safety And Compensation Commission, Nanavut, Canada Page 4
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4Worker sign-off
I acknowledge that I have reviewed the fall protection requirements and procedures for this site with my
supervisor and understand my responsibilities, specifically the requirement to use personal fall protection.
Name (please print)
Signature
Company
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Supervisor name:
Supervisor signature:
Date:
WSCC Emergency Reporting
1 800 661-0792
24-hour Incident Reporting Line
page 4 of 4
WRITTEN SITE-SPECIFIC FALL PROTECTION PLAN – 09.2014
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