Appendix A: Sample Fall Prevention Plan

Policy for Fall Prevention (FPP Component #1)

Workplace Details

Company Name

Workplace Address

Workplace Number

Fall Prevention Policy

(Signature)
Name/ Designation/ Date

Responsibilities (FPP Component #2)

Manager

Safety Assessor

Supervisor

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Hazards Identification and Risk Assessment (FPP Components #3, #4 and #5)

Identification of Fall from Heights Hazards and Control Measures Implemented

S/N Fall Hazards Location Control Measures SWP No. SWP Title
(list specific fall hazards in the work area, (insert sketch/ photo if necessary) (list specific control measures for each hazard; (if any) (List relevant SWPs for
e.g., open sides, unprotected openings) insert sketch/ photo if necessary) control measures implemented)

To be attached with: Inventory of WAH activities/ Risk Assessment form (see Code of Practice on WSH Risk Management); relevant SWP documents.

Personal Protective Equipment for Work at Heights (FPP Components #6 and #7)

Selection of Personal Protective Equipment (for WAH)

S/N Description of PPE (for WAH) Quantity Issued Inspection/ Maintenance Inspected/ Maintained by
(e.g., travel restraint PPE, Full-body harness) Frequency

Personal Fall Prevention/ Arrest Systems

S/N Description of Personal Fall Prevention/ Arrest Systems Quantity Inspection/ Maintenance Inspected/ Maintained by
(e.g., travel restraint system, fall arrest system) Installed Frequency

To be attached with: Relevant certification by competent person; inspection/ maintenance records.

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Instruction and Training (FPP Component #8)

WAH Training and Communication Master List

S/N Title of WAH Training Trainees Level Frequency Conducted By

(e.g., WAH Course for Supervisors, toolbox meeting) (e.g., workers, supervisors)

To be attached with: Training/ communication records.

 Accident/ Incident Investigation (FPP Component #9)

Fall from Heights Investigation Reports

Doc Incident Description Date of Parties Informed

No. Incident

To be attached with: Relevant incident investigation reports.

Emergency Response (FPP Component #10)

Emergency Response Team Contact List

Fall Rescue Equipment/ Procedures

(attach sketch/ photo if necessary)

To be attached with: Emergency Response Team training records; inspection/ maintenance records of fall rescue equipment.

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