Contents

PROJECT FALL PROTECTION EVALUATION FORM (Fall Protection Eval: Page 1 of 1)
This form is to be completed by CH2M HILL project SSC or DSC prior to performing activities that expose CH2M HILL personnel to fall hazards.
The form is used to: 1) identify project fall hazards and determine fall protection systems available to mitigate the hazards, 2) identify personal fall
arrest system equipment required, and 3) provide project-specific fall protection training. Activities and work locations must be evaluated to
determine potential fall hazards. If personnel are exposed to fall hazards greater than 6’ during construction activities or 4’ during general industry
activities, fall protection systems must be used.
PROJECT INFORMATION
Project Name: ___________________________________________________Project Number: ________________ Date: ______________
Scope of Work: ___________________________________________________________________________________________________
Work Area: ____________________________________________________________________ Maximum Working Height: __________
Describe fall hazard activities: _______________________________________________________________________________________
FALL HAZARD
FALL HAZARD DETERMINATION & FALL PROTECTION SYSTEMS
CONVENTIONAL SYSTEMS ALTERNATIVE SYSTEMS
Guardrail Safety Net PFAS Cover Positioning
Device
Warning
Line
Controlled
Access Zone
Safety
Monitoring
Unprotected sides & edges
Leading edges *
Holes
Wall openings
Ramps, runways & walkways
Hoist areas
Excavations
Wells, pits & shafts
Dangerous equipment
Formwork & reinforcing steel work
Precast concrete erection *
Overhand bricklaying
Low-slope roofing work
Steep roof
Residential construction *
Other surfaces
*Fall protection plans may only be used if conventional systems are determined to be infeasible or would create a greater hazard. Contact HS&E Staff for plan
development.
PERSONAL FALL ARREST SYSTEM EQUIPMENT REQUIRED
Full body harness Lanyard, standard Lifeline, horizontal
Boatswain’s chair Lanyard, shock-absorbing Lifeline, vertical
Descent system Lanyard, ripstitch Lifeline, self-retracting
Rope grab Lanyard, self-retracting Winch
Other equipment:
TRAINING REQUIREMENTS
Fall
Protection
Plan
The SSC or DSC shall use this form to inform project staff of the potential fall hazards and specific fall protection systems to be used to control
the hazards. SSC or DSC shall instruct staff on the proper use, limitations, and inspection procedures for each fall protection component and
system.
___________________________________________________
____________________________
SSC or DSC Signature
Date
GNV310133632156.DOC/090840008 A-69