Rescue Plan

IMPORTANT: This document is intended to provide guidance only for

developing site-specific working at heights rescue plans.

Date: _______________________________ Job Description: _______________________________

__________________________________________________________________________________

Location:__________________________________________________________________________

__________________________________________________________________________________

Contacts Rescue Equipment Critical Rescue Factors

Rescuer(s) ________________
__________________________
Competent
Person____________________
Emergency
Contact ___________________
Method of Contact:
□ PA
□ Verbal/Face to face
□ Radio Channel:
________________________
□ Phone Number:
________________________
□ Other
________________________
□ Ladder □ RSQ
Anchor Point _______________
□ Rescue Pole □ First Aid Kit __________________________
□ Rescue Rope □ Life Ring __________________________
□ Crane □ RPD
□ Scaffold □ R500
□ Arial Lift Landing Area _______________
□ Alternative Lifting & Lowering __________________________
Device __________________________
Location of Equipment:
Rescue Obstructions/Hazards:
□ Job Site __________________________
□ Gang Box __________________________
□ Tool House __________________________
□ ________________________ __________________________
__________________________ __________________________

Check for Yes Comments

□ Have alternatives to using fall arrest equipment been considered? ___________________________
□ Has rescue equipment been inspected and found in good shape? ____________________________
□ Is equipment adequate for the rescue plan? _____________________________________________
□ Have communication devices been identified, located, & tested? _____________________________
□ Are all rescuers familiar with the use of the rescue equipment? ______________________________
□ If working over water, is there a boat available? __________________________________________

Describe the tasks that will be done prior to work to prevent a fall and the step by step process that
will be followed in the event of a fall.

Pre Work Tasks: Response Procedure:

1) ___________________________________
2) ___________________________________
3) ___________________________________
4) ___________________________________
5) ___________________________________
6) ___________________________________
1) Notify Emergency Contact.
2) Make medical assessment of person.
3) If possible have employee perform self-rescue.
4) ___________________________________
5) ___________________________________
6) ___________________________________