ROOF FALL PROTECTION WORK PLAN
Job Location: Date:
Describe the Job task:
1. Identify all potential fall hazards in the work area that are 4 feet or more above the ground or lower level:
Unprotected sides & edges of rooftops or floors
Unprotected sides & edges of roof hatches & ladder platforms
Elevated work platforms
Fixed Ladders
Describe the hazards:
2. Method of fall protection to be used:
Guardrails
Unprotected sides & edges of runways, ramps, platforms & dockboards
Wall or floor openings including skylights
Fixed ladders over 24 feet in height Swing fall
Wall openings
Pit
Fall clearance
Other :
Safety Net
Designated Area Warning Line
Covers (for holes & openings)
Describe:
Horizontal Life Line
Fall Restraint System* Fall Arrest System**
Work Plan
Safety Monitor
*-Fall Restraint System (horizontal cable or track system, or counterweighted single point anchor)
Other:
**-Fall Arrest System (anchorages used to suspend workers or equipment or as a suspended equipment tieback or for vertical safety lines)
3. Describe procedures for assembly, maintenance, inspection, and disassembly of the fall protection system to be used:
4. Describe procedures for handling, storage, and securing of tools and materials to provide falling object protection:
5. Describe methods of overhead falling object protection for employees & those who may be in, or pass through, the area below the work site (i.e. barricading, hard hats required, toe boards, warning signs):
6. Describe methods for promptly rescuing employees in an event of a fall and/or removal of injured employees:
7. If fall restraint systems or fall arrest anchors are being used; select the method used to certify the capability of the equipment:
Inspection/Testing/Certification Documentation from Qualified Person
Other (describe):
Inspection/Testing/Certification Documentation from Professional Engineer
Pre-Use Inspection by User
Date of Inspection:
Name of Inspector:
Date of Inspection/Testing Certification:
8. List employees who received fall protection training at this site and who are required to follow this plan:
Name
Name/title of person provided training: Use back of sheet if necessary.
9. Identify the safety monitor(s), if any:
Training Date
10. Justify selecting controlled access zone and/or safety monitor, if any:
Fall Protection Plan Completed by:
Name: Signature: Date:
Site Approval
Name: Signature: Date:
Project Manager Approval
Name: Signature: Date: