Work at Heights Rescue Plan Form
Complete this form to document the work-at-heights rescue plan, equipment, hazards, emergency contacts, and readiness before work begins.
Incident and Work Location
Job/Project Identifier
*
Work Location / Area Description
*
Planned Work Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Work-at-Heights Activity
*
Roofing
Scaffolding
Ladder Work
Elevated Platform
Tower/Mast
Other
Rescue Planning Details
Maximum Work Height or Elevation Range
*
Anticipated Number of Workers at Height
*
Rescue Method
*
Self-rescue
Assisted rescue
Mechanical lowering
Rope rescue
Site-specific method
Rescue Equipment Available On Site
*
Harness
Lanyard
Rescue kit
Anchor system
Stretcher
First-aid kit
Radio/communication device
Other
Site Hazards or Access Constraints Affecting Rescue
Emergency Response and Approval
Onsite Rescue Lead or Supervisor Name
*
First Name
Last Name
Onsite Rescue Lead or Supervisor Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Onsite Rescue Lead or Supervisor Role
*
Nearest Emergency Services or Hospital Contact Details / Dispatch Instructions
*
Rescue Plan Approval Status
*
Approved
Approved with Actions Required
Not Ready
Submit
Should be Empty: