Working at Height Rescue Form

Working at Height Rescue Form
Use this form to record and coordinate a rescue incident involving work at height, including incident details, people involved, hazards, equipment, response actions, and follow-up.
Incident Details
Incident Date and Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Site Name
Exact Location at Height
Work Area / Access Point
Incident Summary
Affected Person Information
Affected Person Name
First NameMiddle NameLast Name
Job Role / Company
Contact Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Status / Injury Description
Rescue Situation and Hazards
Type of Height Work
Fall-Arrest or Access System in Use
Cause of the Emergency
Height Involved (m)
Existing Hazards
Other
Weather / Environment Conditions
Person Status
Rescue Team and Equipment
Rescue Team Lead Name
First NameMiddle NameLast Name
Team Members Present
Rescue Method Used
Other
Equipment and PPE Used
Other
Equipment Condition Checks
Rows Checked Pass Issue Noted
Harness
Lanyard
Ropes/Lines
Anchorage points
Connectors/Carabiners
Rescue device
PPE
Access/Egress Limitations
Medical, Communication, and Outcome
First Aid Provided
Emergency Medical Services Called?
Communication Steps Taken
Rescue Start Date and Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Rescue End Date and Time
MonthDayYear
Date
Hour MinutesAM/PM Option
Outcome / Status After Rescue
Lessons Learned
Immediate Corrective and Follow-up Actions
Should be Empty:

Select theme: