Fillable Printable Form 417-102-000
Fillable Printable Form 417-102-000
Form 417-102-000
F417-102-000 Competent Person Evaluation Fall Restraint & Fall Arrest 03-2017
Competent Person Evaluation
Fall Restraint & Fall Arrest
This checklist has been devised to help/assist the employer determine if the person he/she has designated as a
Competent Person is competent within the description and intent of the Fall Restraint and Fall Arrest Standard,
WAC 296-155-24603.
Employee’s Name
Position
Date of Evaluation by Employer
Length of Time with Employer
Length of Experience in Fall Protection
Training:
Does the designated individual have training in:
Yes
No
Use of fall protection equipment.
Inspection requirements of fall protection
equipment.
Maintenance of fall protection equipment.
Storage of fall protection equipment.
Identifying fall hazards.
Requirements of the fall restraint and &
fall arrest standards.
Knowledge:
Does the individual have knowledge about:
Yes
No
Fall hazards.
Manufacturer’s recommendations and
instructions for the proper use,
inspection, and maintenance.
Requirement of the standards.
Fall protection work plans.
Emergency removal.
Authority:
Does the designated individual have authority to:
Yes
No
Take prompt corrective measures to eliminate existing and predicable hazards?
Stop work until hazards are corrected or eliminated or controlled, and remove employees from the
hazardous area until proper systems are in place?
Comments:
Yes
No
Do you consider the individual to be competent within the requirements of the fall restraint and fall
arrest standard?
If not, why? Areas to be strengthened?
Continue of reverse if more space is needed
Signature:
Print Employer/Representative Name
Employer/Representative Signature
RESET
