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Identify all fall hazards 10 feet or more (Washington)

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F417-272-000 Fall Protection Work Plan 11-2020
Fall Protection Work Plan
WAC 296-880-10020: You must develop and implement a written fall protection work plan including each area of the work
place where the employees are assigned and where fall hazards of 10 feet or more exist and be available on the job site
for inspection by the department.
Company Name
Date
Site Address
(If additional space is needed, use the back of the sheet.)
Identify all fall hazards 10 feet or more above the ground or lower level. Check all that apply.
Open-sided floors
Leading edge work
Decks/Balconies
Mobile lift work
Hole
Methods of fall protect to be used: (LSO = Low Slopes Only. Low Slope = 4 x 12 or less)
Personal fall arrest system
Safety watch system (LSO)
Warning line system (LSO)
Catch platform
Positioning device system
Safety net
Covers
Horizontal life lines
Vertical life lines & rope grab
Personal fall restraint system
Warning line with safety monitor (LSO)
Name of safety watch or monitor (if used):
Overhead Hazard Protection Methods
Hard Hats
Toe boards on guardrails
Other:
Overhead Hazard Signs
Screens on guardrails
Other:
Debris Nets
Barricade to control access to area
Describe procedures for assembly, maintenance, inspection, disassembly of fall protection system to be used.
Describe procedures for handling, storage, and securing tools, equipment, and materials.
Describe methods of overhead protection for workers who may be in, or pass through work area.
Describe method for prompt rescue of employees in the event of a fall.
Employees who received fall protection training on the above site specific fall protection work plan.
Name(s):
Date:
The employer or employers’ designee signature verifies that employees are trained and instructed on the plan:
Name:
Title:
Date:
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Identify all fall hazards 10 feet or more (Washington)

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Completed 18 January 2022

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