|
||||||||
|
Fall Hazard Survey Report |
||||||||
|
Report Date: |
|
|
Report Completed By: |
|
|
|||
|
Facility Name: |
|
|
Risk Rating*** |
|
|
|||
|
Location Description: |
|
|
|
|||||
|
|
|
|
||||||
|
Fall Hazard Description: |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
Current and predictable paths of
Authorized Persons |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
Describe any additional Fall
Hazards along the paths |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
Describe the Locations and
Distances to Obstructions in the Fall Path |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
Circumstances and Environmental Factors*
that Affect Use** of Fall Protection Equipment |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
If this is a revision, describe
any changes to the task, process, structure, equipment, or regulations. |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
Methods of Eliminating or
Controlling this Fall Hazard |
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
||
|
|
|||||||
|
Fall Hazard Photo #1 - (example shown) |
Fall Hazard Photo #2 |
|||||||
|
* Environmental Factors include: hotobjects, spakrs, flames, heat-producing
operations, hazardous chemicals, electrical hazards, contaminants, sharp
objects and abrasive surfaces, moving equipiment, and materials, unstable, uneven and
slippery surfaces, unguarded openings, climatic and weather factors. |
||||||||
|
** Use refers to - Installation, Use,
Inspection, Maintenance, or Dismantling of Fall Protection Equipment. |
||||||||
|
***Risk Rating is obtained from the
Template_RiskAssessment.doc and Template_RiskDefinition.doc. |
||||||||
|
©MSA-FP,
2007 |
||||||||
