Aerial Lift Rescue Checklist
Use this form to document aerial lift rescue readiness, hazards, equipment, rescue method, and completion details.
Incident and Job Information
Incident/Report Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Site or Location
*
Company/Crew or Team Name
*
Supervisor or Lead Responder Name
*
Aerial Lift Type/Model
*
Rescue Readiness and Hazard Assessment
Aerial lift status
*
Stopped
Stalled
Damaged
Unstable
Other
Number of workers affected or involved
*
Weather and visibility conditions
*
Please Select
Clear
Rain
Wind
Lightning
Poor visibility
Snow
Other
Immediate hazards observed
*
Overhead obstructions
Electrical exposure
Unstable ground
Fall hazard
Dropped-object hazard
Traffic exposure
Other
Area secured or barricaded
*
Yes
No
Equipment, Access, and Rescue Plan
Available Rescue Equipment
*
Harness
Lanyard
Lowering Device
Ropes
Anchor Point
Communication Device
First Aid Kit
Other
Access Method to Reach Worker(s)
*
Please Select
Aerial lift platform
Ground access
Ladder access
Alternative access method
Other
Rescue Method Selected
*
Assisted descent
Platform transfer
Ground-based retrieval
Other
Communication Status with Worker(s)
*
Confirmed
Intermittent
Lost
Not applicable
Rescue Plan Ready to Execute
*
Yes
No
Completion and Follow-up
Rescue Status
*
Completed
In Progress
Not Started
Aborted
Time Rescue Completed
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Injuries or Medical Attention Required?
*
No
Yes
Injuries or Medical Details
Equipment Removed from Service or Requiring Inspection
Corrective Actions or Notes
Responder Acknowledgment
Submit
Submit
Should be Empty: