Fall Protection Plan Form
Fall Protection Plan Form
Fall Protection Plan Form
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:
SAF010714
Calculation of Fixed Anchor Vertical & Swing Fall Clearance Distance
Length (Meters)
Worker Worker
1 2
A Length of Lanyard
B Shock Absorber Elongated
Harness Stretch (from top of
C
worker’s head)
D Height of Worker
E Safety Factor (0.6M) 0.6 0.6
Overall Minimum Clearance
F
Beneath the Anchor
Worker # 2 - Name:
SAF010714
Describe the Steps for the Assembly, Use and Disassembly of the Fall Protection System
Rescue Plan (Procedure to follow if a worker falls or needs to be rescued. Attach as necessary. If Personal Fall Arrest System is to be used,
discuss Suspension Trauma with Workers) Different types of Rescue to discuss; Self Rescue ,Climb or pull yourself to safety, Assisted Self Rescue,
Suspension Trauma Safety Straps, Ladders, Mechanically Aided Lifts, Rescue Pick-off (Almost Never)
Procedures for Handling, Storing and Securing Tools and Materials while using Fall Protection (brief
description of plan to avoid dropping tools or materials or losing balance or footing)
SAF010714
Inspection of Fall Protection Systems
System Schedule Person Responsible
Guardrails
Temp Flooring
Personnel Net
Travel restraint
Fall Arrest
Work Positioning
Worker Acknowledgement
By signing this Fall Protection Plan the workers acknowledge they have received training concerning the
proper use of the fall protection equipment, are familiar with the hazards and understand the Fall Protection
Procedure and the contents of this Fall Protection Plan.
Print Name Signature Date (mm/dd/yy)
SAF010714
***REVIEW BEFORE STARTING WORK***
ALL personnel who have been suspended in an arrested fall should be treated as a medical emergency and
immediate medical attention sought.
SAF010714