Fall Protection Plan Template
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5F
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ALL
ROTECTION
LAN
To be completed when working at 7.5 meters or more in addition to the Fall Hazards Assessment form
(SAF030714) and the Working at Height Safe Work Procedure form (SAF020714).
Job Number:
Date:
) Appendix B &C
Job Location:
Job Task:
Signature:
Completed By:
Site / Task Specific Information
Nature of work:
Duration of work:
Description of work:
Tools & Equipment used
Regulations that apply to work:
Effects of weather:
Designated Competent Supervisor:
Training Required:
Fall Protection Systems to be used (
)
Check all that apply
Travel Restraint
Guardrails / Temporary Flooring/ Nets
Personal Fall Arrest
Work Positioning
Fall Protection System Components to be used (
Check all that apply)
Full Body Harness
Lanyard
Connecting Devices
Self Retracting Devices
Vertical Life Line
Carabineer
Fall Arrestor/Rope Grab
_______________
Horizontal Life Line
Anchorage
Work positioning Rope
_______________
Anchor Point Locations and Description
SAF010714
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