Fall Protection Inspection Form - Delta Services

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Fall Protection Inspection

Site:
Date
MM slash DD slash YYYY
IF ITEM FAILS INSPECTION, DO NOT USE AND REMOVE FROM SERVICE
Employee Name:
FULL BODY HARNESS*
- Safe
- Unsafe
SHOCK ABSORBING LANYARD*
- Safe
- Unsafe
POSITIONING LANYARD*
- Safe
- Unsafe
Signature
POLE CINCH SYSTEM*
- Safe
- Unsafe
SELF RETRACTING LANYARD*
- Safe
- Unsafe
Item has failed inspection: remove from service!

4676 Jennings Lane
Louisville, KY 40218

502-491-2202

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