Barrier Protection Assessment Form
Use this form to assess the presence, condition, and effectiveness of physical barriers at your facility or worksite.
Assessor Name
*
First Name
Last Name
Assessment Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Assessment Location
*
Type of Barrier Being Assessed
*
Please Select
Guardrail
Handrail
Fencing
Bollard
Safety Netting
Other
Barrier Condition Checklist
Rows
Present
Undamaged
Properly Installed
Clearly Visible
Meets Height Requirements
Barrier 1
1
2
3
4
5
Barrier 2
6
7
8
9
10
Barrier 3
11
12
13
14
15
Are warning signs present and clearly visible near the barrier?
*
Yes
No
Not Applicable
Is the barrier free from obstructions or modifications?
*
Yes
No
Not Applicable
Overall Effectiveness of the Barrier
*
1
2
3
4
5
Observations or Issues Noted
Recommendations for Improvement
Upload Photos of the Barrier (if applicable)
Upload a File
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of
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