Fall Hazard-Rescue Plan Example



Fall Arrest Rescue Plan

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|Date: Job Description: |

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|Location: |

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|Contacts |Rescue Equipment |Critical Rescue Factors |

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|Rescuer(s) |□ Ladder □ Block & Tackle |Anchor Point |

| |□ Rescue Pole □ First Aid Kit | |

| |□ Rescue Rope □ Life Ring | |

|Competent |□ Spider □ Work Vest | |

|Person |□ Scaffold □ (Cutting Device) |Landing Area |

| |□ Stokes Litter | |

|Emergency |□ Alternative Lifting & Lowering Device | |

|Contact | | |

| | |Rescue Obstructions/Hazards: |

|Method of Contact: |Location of Equipment: | |

|□ PA □ Verbal/Face to face |□ Job Site □ Gang Box | |

|□ Radio Channel: |□ Tool House □ ____________ | |

|□ Phone Number: | | |

|□ Other | | |

|Check for Yes |Comment |

|□ Have alternatives to using fall arrest equipment been considered? | |

|□ Has rescue equipment been inspected and found in good shape? | |

|□ Is equipment adequate for the rescue plan (weight ratings, length, connection type, etc.)? | |

|□ Have communication devices been identified, located, & tested? | |

|□ Are all rescuers familiar with the use of the rescue equipment? | |

|□ If working over water, is there a boat available? | |

|Pre Work Tasks: |Response Procedure: |

|1) |Notify Emergency Contact. |

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|2) |Make medical assessment of person. |

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|3) |3) |

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|4) |4) |

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|5) |5) |

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|6) |6) |

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