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Fall Protection Equipment Use Form

This form is to document the proper use of fall protection equipment for safety and compliance purposes.
Delong - Clinton
03/08/2024

Fall Protection Equipment Use Form

This form is to document the proper use of fall protection equipment for safety and compliance purposes.

    Date

    Name

    Specific Area Equipment Will Be Used

    Inventory - Check Items To Be Used

    Equipment inventory being used must be inspected and checked off prior to use as per below:

    Harness being used?

    if the answer is "oneOf [Yes]"

    Harness

    Lanyard being used?

    if the answer is "oneOf [Yes]"

    Lanyards

    Tie-Off Adaptor being used?

    if the answer is "oneOf [Yes]"

    Tie-Off Adaptors

    Rope Grabs / Carabiner being used?

    if the answer is "oneOf [Yes]"

    Rope Grabs / Carabiner

    SRL being used?

    if the answer is "oneOf [Yes]"

    Self-Retracting Lifelines (SRL)

    Lifeline being used?

    if the answer is "oneOf [Yes]"

    Lifelines

    Trained and understand proper use of FPE (Fall Protection Equipment).

    • Yes
    • No
    • N / A

    Notified Supervisor of use

    • Yes
    • No
    • N / A

    Equipment is good for use

    • Pass
    • Flag
    • Fail

    Signature

    Click here to sign
Source: Delong - Clinton (Community Member)

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