Taken from OSHA's website.
FLS recommends using the following only as an example. Most sites will be more specific; the customer's safety representative should develop a detailed plan

6.1 BC Construction Industry Health & Safety Council Site Specific Fall Protection Plan

6.1.1 Employer Responsibilities

· Ensure a written worksite specific fall protection plan is in place.
· Ensure that a fall Protection System is being used.
· Ensure that guardrails are used when practicable.
· Ensure a Fall Restraint system is in place when applicable.
· If a Fall Restraint cannot be used, ensure a Fall Arrest system is in place.
· Provide appropriate Control Zone procedures if the above are not appropriate.
· Ensure supervisors and workers are trained.
· Ensure all equipment is safe, maintained, inspected and used correctly.
· Investigate any anomalies in the system to make recommendations so that such anomalies will not happen again.
· Update the program as needed.
· Follow up on our program.

6.1.2 Supervisor Responsibilities

· Ensure the program is prepared for each site.
· Ensure the program is being implemented.
· Inspect the program as it is used.
· Review the program
· Investigate any anomalies and make recommendations to prevent reoccurrence.
· Investigate all workers reports of anomalies to the system.
· Keep a log of all workers trained for the fall protection program and topics that were covered before they work in the fall protected area.
· Ensure all workers have a copy of the fall protection program.
· Inspect, maintain, and use the equipment in the recommended methods.
· Ensure that all workers are provided with the appropriate equipment.
· Observe workers, work practices and site operations and correct when necessary.

6.1.3 Worker Responsibilities

· Know the fall protection plan.
· Follow the procedures, as trained.
· Inspect equipment.
· Maintain equipment.
· Report any anomalies to the supervisors.
· Ensure the equipment is used as the manufacturer recommends.
· To inspect the program.
· It is a condition of employment that all managers, supervisors, and workers comply with the company safety policy and safety programs.

6.1.4 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:

Help prevent falls
Assist workers and supervisors to identify the fall hazards of the site before work begins at heights.
Assist in the selection of an appropriate fall protection system(s)
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.

6.1.5 Site specific Fall Protection Work Program

Company: _______________________________________________________

Address: ________________________________________________________

Phone: __________________________________________________________

Date: ___________________________________________________________

Project: _________________________________________________________

Location: ________________________________________________________

Phone: __________________________________________________________

Date: ___________________________________________________________

Supervisor: ______________________________________________________

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:

Control Zone

Is a control zone used: Yes: No:

If Yes where: _____________________________________________________

Is the control zone marked: Yes: No:

How: ___________________________________________________________

What is the set-back distance of the control zone area: Metres: Feet:

The Safety Monitor

Name of Safety Monitor: ___________________________________________

Safety Monitor Training: ___________________________________________

Date Trained: ____________________________________________________

Number of workers to be monitored: __________________________________

Journeyman: _____________________________________________________

Apprentices: _____________________________________________________

All the following Workers have been trained in the Safety monitor system:

Date: ___________________________________________________________

1. __________________________________________________________

2. __________________________________________________________

3. __________________________________________________________

4. __________________________________________________________

5. __________________________________________________________

6. __________________________________________________________

7. __________________________________________________________

8. __________________________________________________________

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:

Other considerations:

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:

Other considerations:

Describe in detail the procedure to be followed if someone is to be rescued after a fall occurs:

Other concerns or considerations:

Hazard Identification

Name of Hazard Yes No
Scaffold Work. .
Lock Out. .
Walls. .
Floor Openings. .
Edge of Slab. .
Electrical Hazards. .
Other Trades. .
Manholes. .
Shafts. .
Doors. .
Tripping Hazards. .
Drop Off Points. .
Fly forms. .
Swing Stages. .
Excavations. .
Crane Operations. .
Work Access Above.
Walkways Above.

Type of Fall Protection Name .
Guardrails .
Toe Boards .
Horizontal Lifelines .
Vertical Lifelines .
Harness and Lanyard .
Belt and Lanyard .
Warning Lines .
Cover Over Holes .
Wire Rope Lifeline .
Fiber Rope Lifeline .
Robe Grab .
Fall Arrest Block .
Tie Backs .
Safety Nets .
Canopies

Describe in detail all work procedures including hazard identification, assembly, maintenance, use, disassembly, and inspection of the equipment, system and / or area. Ensure all required equipment is provided, identified, inspected, and put in a log book before use.

Equipment Log

Equipment Name. Equipment # Date Inspected Date Removed
Safety Belts
Harnesses Safety Lines
Lanyards
Horizontal Life
Lines
Nets
Platforms
Rebar Guards
Guardrails. . .

All workers who will be exposed to fall hazards are informed of those hazards, and are instructed in the fall protection system to be used and the procedures to be followed. All contents of this program have been conveyed to the workers. All necessary equipment has been provided.

Site Superintendent: ____________________________________________________

Signature: ____________________________________________________________

Print Name: ___________________________________________________________

Date: ________________________________________________________________

Site Safety Representative: _______________________________________________

Signature: ____________________________________________________________

Print Name: ___________________________________________________________

Date: ________________________________________________________________