Company Policy Statement
Company Name and Address:
We at ____________________________________ believe that our employees are very important to us. Fall Protection is an important aspect of our program to insure that people who work for us can continue to live safe and healthy lives.
We at ____________________________________ require all employees who work at heights above 10 feet and over to be protected from falling. In some cases we will also implement fall protection at a lesser height if there is a danger or hazard in the area below. A written fall protection plan will be developed and implemented when a fall hazard of 25 feet or more exists or when a safety monitor and control zone is required. The intent of the plan is to:
1) help prevent falls
2) assist workers and supervisors to identify the fall hazards of the site before work begins at heights.
3) assist in the selection of an appropriate fall protection system(s)
4) assist in rescue procedures for someone if a fall should occur.
It is our company policy that all managers, supervisors and workers comply with the fall protection guidelines we have established.
We have several checklists to help our supervisors and workers in identifying problem areas on the site. These checklists will be of much help when our supervisors are developing the site specific program.
We have outlined some specific responsibilities for ourselves (the employer), our supervisors and our workers as follows:
Signature of Management and Date
Site specific Fall Protection Work Program
Site Safety Representative:
Job Description and Type of Work:
New: Alterations: Demolition: Maintenance: Repair:
Specific Work Area:
A brief description of the type of work being done:
Is a control zone used: Yes: No:
If Yes where:
Is the control zone marked: Yes: No:
What is the set-back distance of the control zone area:
The Safety Monitor
Name of Safety Monitor:
Safety Monitor Training:
Number of workers to be monitored:
All the following Workers have been trained in the Safety monitor system:
Describe the type of work being done:
List the Fall Hazards:
Draw a diagram of the control zone:
Describe the type of Fall Protection System to be used:
Describe the type of work being done in other Fall Hazard areas:
List the Fall Hazards:
Draw a diagram if necessary:
Describe the type of fall protection system to be used:
Describe in detail the procedure to be followed if someone is to be rescued after a fall occurs:
Other concerns or considerations: