Extension Ladder Tie-Off Safety Checklist Form
Complete this checklist to document the safety and readiness of an extension ladder before use.
Inspection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job/Site Location
*
Inspector Name
*
First Name
Last Name
Ladder Identification (Serial or Asset Number)
*
Ladder Type/Size
*
Please Select
Fiberglass
Aluminum
Wood
Other
Ladder Size (Length in feet)
*
Tie-Off Anchor Condition
*
Good (no visible damage, secure)
Needs Attention (minor issues)
Unsuitable (not secure or damaged)
Is the ladder properly secured at the top?
*
Yes
No
Is the ladder stable at the base?
*
Yes
No
Defects or Hazards Observed
Final Safety Decision
*
Pass (Ready for Use)
Fail (Not Ready for Use)
Notes for Corrective Action (if applicable)
Submit Checklist
Should be Empty: