3M Fall Protection Inspection Form

1 fall ProtectionFull Body HarnessesHarness Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR : (Includes D-rings, buckles,keepers, and back pads) Inspect for dam-age, distortion, sharp edges, burrs, cracksand : Inspect for cuts, burns, tears,abrasion, frays, excessive soiling and : Inspect for pulled or : Inspect, make certain all labels aresecurely held in place and DispositionINSPECTED BY: _____DATE INSPECTED: _____Inspection checklist /LogsAppendixRelease 2, October 2017 ACCEPTEDREJECTEDACCEPTEDREJECTEDACCEPTED REJECTEDACCEPTEDREJECTEDACCEPTEDREJECTED ACCEPTEDREJECTEDACCEPTEDREJECTEDACCEPTED REJECTEDD istributed by Engineered fall Protection | | (314) 492-4422 | Appendix: Inspection checklist /Logs- Release 2, October 20173M Personal Safety DivisionLanyardsLanyard Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR : (Includes snap hooks,carabiners, adjusters, keepers, thimblesand D-rings).

2 Inspect for damage,distortion, sharp edges, burrs, cracks,corrosion and proper : Inspect for cuts, burns, tears,abrasion, frays, excessive soiling : Inspect for pulled or Rope: Inspect for pulled or cutyarns, burns, abrasion, knots, excessivesoiling and Rope: Inspect for broken wires,corrosion, kinks and separation of Absorbing Component: Inspectfor elongation, tears and excessive : Inspect, make certain all labels aresecurely held in place and DispositionINSPECTED BY: _____DATE INSPECTED: _____ACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDA ppendix: Inspection checklist /Logs- Release 2, October 201733M Personal Safety DivisionTie-Off AdaptorsTie-Off Adaptor Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR : (Includes D-rings) Inspect fordamage, distortion, sharp edges, burrs,cracks and : Inspect for cuts, burns, tears,abrasion, frays, excessive soiling : Inspect for pulled or : Inspect, make certain all labels aresecurely held in place and DispositionINSPECTED BY: _____DATE INSPECTED: _____ACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTED4 Appendix: Inspection checklist /Logs- Release 2, October 20173M Personal Safety DivisionHooks/CarabinersHook/Carabiner Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR Damage: Inspect for cracks,sharp edges, burrs, deformities and locking Corrosion: Inspect forcorrosion which effects the operationand/or : Inspect, make sure certainmarking(s) are DispositionINSPECTED BY: _____DATE INSPECTED.

3 _____ACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDA ppendix: Inspection checklist /Logs- Release 2, October 201753M Personal Safety DivisionAnchorage PlatesAnchorage Plate Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR Damage: Inspect for cracks,sharp edges, burrs, deformities and locking Corrosion: Inspect forcorrosion which effects the operationand/or : Inspect for corrosion, tightness, damage and distortion. If welded, inspectweld for corrosion, cracks and : Inspect, make sure certainmarking(s) are DispositionINSPECTED BY: _____DATE INSPECTED: _____ACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTED6 Appendix: Inspection checklist /Logs- Release 2, October 20173M Personal Safety DivisionSelf Retracting LifelinesAnchorage Plate Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR Indicator: Inspect indicator foractivation (rupture of red stitching, elon-gated indicator, etc.)

4 : Inspect for damageand make certain all screws and fastenersare : Inspect for distortion, cracks and other damage. Inspect anchoring loop fordistortion and : Inspect for cuts, burns, tears,abrasion, frays, excessive soiling anddiscoloration, broken wires (see impactindicator section). Action: Inspect for proper lock-up of brake : Inspect springtension by pulling lifeline out fully andallowing it to retract fully (no slack). : Inspect for physicaldamage, corrosion, proper operation andmarkings (see separate checklist /log forhooks and carabiners). Lifeline: Inspect reserve lifelineretention systems for : Inspect, make certain all labels aresecurely held in place and DispositionINSPECTED BY: _____DATE INSPECTED: _____ACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDACCEPTEDREJECTEDACCEPTEDREJECTEDACC EPTEDREJECTEDACCEPTEDREJECTEDACCEPTEDREJ ECTEDA ppendix: Inspection checklist /Logs- Release 2, October 201773M Personal Safety DivisionInspection checklist /Log_____ Model: _____ Manufacture Date: _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR DispositionINSPECTED BY: _____DATE INSPECTED: _____ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED ACCEPTEDREJECTED 8 Appendix: Inspection checklist /Logs- Release 2, October 20173M Personal Safety DivisionInspection checklist /Log_____ Model: _____ Manufacture Date.

5 _____Serial Number: _____ Lot Number: _____ Purchase Date: _____Comments: _____GENERAL FACTORSACCEPTED/REJECTEDSUPPORTIVE DETAILS OR DispositionINSPECTED BY: _____DATE INSPECTED: _____3M Personal Safety DivisionFall Protection Equipment Inspection LogGreen: Pass, Safe for Use Red: Remove from Service - Send to Manufacturer for Inspection /Servicing Black: Destroy ImmediatelySERIAL #DATE OF #DESCRIPTIONINSPECTION DATEPASSFAILINSPECTED BYINSPECTION DATEPASSFAILINSPECTED BYINSPECTION DATEPASSFAILINSPECTED BYCOMMENTSC lassification _____ Company _____Distributed by Engineered fall Protection | | (314) 492-4422 |