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
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Site Name
*
Exact Location at Height
*
Work Area / Access Point
*
Incident Summary
*
Affected Person Information
Affected Person Name
*
First Name
Middle Name
Last 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
*
Please Select
Roof work
Scaffolding
Ladder work
MeWP/Cherry picker
Steel erection
Confined space access
Tower/climbing structure
Other
Fall-Arrest or Access System in Use
*
Please Select
Fall-arrest harness
Work positioning system
Travel restraint system
Ladder system
Scaffold platform
MeWP basket
Rope access system
Other
Cause of the Emergency
*
Height Involved (m)
*
Existing Hazards
Edges or openings
Falling objects
Electrical hazards
Moving equipment
Confined access
Poor lighting
Wet or slippery surfaces
Obstructions
Other
Weather / Environment Conditions
Please Select
Clear and dry
Wet or rainy
Windy
Cold
Hot
Low visibility
Indoor
Night work
Other
Person Status
*
Suspended
Injured
Unconscious
Able to assist
Rescue Team and Equipment
Rescue Team Lead Name
*
First Name
Middle Name
Last Name
Team Members Present
*
Rescue Method Used
*
Lowering
Raising
Pick-off rescue
Controlled descent
Other
Equipment and PPE Used
*
Harness
Lanyard
Lifeline
Rescue rope
Tripod/anchor system
Helmet
Gloves
Eye protection
High-visibility clothing
Other
Equipment Condition Checks
*
Rows
Checked
Pass
Issue Noted
Harness
1
2
3
Lanyard
4
5
6
Ropes/Lines
7
8
9
Anchorage points
10
11
12
Connectors/Carabiners
13
14
15
Rescue device
16
17
18
PPE
19
20
21
Access/Egress Limitations
Medical, Communication, and Outcome
First Aid Provided
Emergency Medical Services Called?
*
Yes
No
Communication Steps Taken
Rescue Start Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Rescue End Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Outcome / Status After Rescue
*
Please Select
Returned to work
Received medical treatment
Transferred to EMS
Hospitalized
Other
Lessons Learned
Immediate Corrective and Follow-up Actions
Submit
Should be Empty: