ࡱ> oqne bjbj 7"x[bx[bB8T$x,tFHHHHHH$;!#jllQQQhFQFQQ@=FXaj20,[$Q[$[$Qll?[$B :  Serial Number or Person Assigned To Use The Equipment Harness Connecting Device Strap Put in Service Date  Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition) Date of Inspection (Initial and ( for good, ( for poor condition)Date of Inspection:  ( and initial to indicate good condition. ( and initial to indicate poor condition and removed from service. Inspection Criteria for PFAS per ANSI Z359.1-1992 *User must inspect before each use. Competent person (other than the user) must inspect at least annually. *Defects, damage, inadequate maintenance shall be removed from service or undergo adequate corrective maintenance. *Inspection criteria (manufacturers instructions plus): Absence or illegibility of markings Absence of any element affecting the equipment form, fit, or function Evidence of defects/damage to hardware: cracks, sharp edges, deformation, corrosion, chemical attack, excessive heating, alteration, excessive wear Evidence of defects to straps/ropes: fraying, unsplicing, unlaying, kinking, knotting, roping, broken or pulled stitches, excessive elongation, chemical attack, excessive soiling, abrasion, alteration, needed or excessive lubrication, excessive aging, excessive wear Alteration, absence of parts, or evidence of defects in, damage to, or improper function of mechanical devices and connectors     Annual Personal Fall Arrest System Inspection Form 9:BCVW]^rst   & ' ; < = O ] ^ i j ~      & ' 2 3 G H I ްh= OJQJ^J# jh= 5CJOJQJ^JaJ# jh= 5CJOJQJ^JaJ#hIKEh= 5CJOJQJ^JaJh= 5CJOJQJ^JaJC#/9:BCUVW]^rst $qq$If]q^qa$gd= qq$If]q^qgd= $$Ifa$gd=  < = P     H I ] ^ _ ` a b c d Ff $$Ifa$gd= I [ \ ^ _ ` a b d g h i j k m n p q 񦕄r`NJ9 hC|+h= CJ(OJQJ^JaJ(h= #h3Bh= 5CJOJQJ^JaJ#h!4h= 5CJOJQJ^JaJ#h!4h= 5CJOJQJ^JaJ hh= CJ OJQJ^JaJ hh= CJ(OJQJ^JaJ(h= OJQJ^J#h@Ah= 5CJOJQJ^JaJ#hOMh= 5CJOJQJ^JaJ#h!4h= 5CJOJQJ^JaJh= 5OJQJ^JhC|+h= 5OJQJ^Jd e kd`$$Ifl4Cִi> $*.j3@80{08    4 laf4yte f g h i j k l m n o p q r s t u v w x y z  $a$gdNFf  $$Ifa$gd= $Ifgd= q x y z {      # òyhThFhFhFhFhFhFhFhFhC|+CJOJQJ^JaJ&hC|+hN5>*CJOJQJ^JaJ hC|+hNCJOJQJ^JaJ&hC|+hN5CJOJQJ\^JaJ h]g5CJOJQJ\^JaJ& jhC|+hNV]CJOJQJ^JaJ hC|+hNV]CJOJQJ^JaJ& jhC|+hNV]CJOJQJ^JaJh= OJQJ^J hC|+h= CJ(OJQJ^JaJ(h= CJ(OJQJ^JaJ( 3 W 1 <$a$gdIKE & F & FgdN 0^`0gdNgdN# H T U W ] ` i l s v |  +.ＴhhIKEh5OJQJ^Jh5OJQJ^Jh cjh cU hC|+hNV]CJOJQJ^JaJhC|+CJOJQJ^JaJ&hC|+hN5>*CJOJQJ^JaJ hC|+hNCJOJQJ^JaJ/51h0:pIKE= /!"#$% $$If!v h#v #v#v#v#v#v 0#v {#v :V l4n08)v,5 55555 05 {5 4f4yt= lkd$$Ifl4n  @ \ xi> $*.j3@8   0{0800004 laf4yt= $$If!vh#v#v#v#v#v0#v{#v:V l4C085555505{54f4yt$$If!v h#v #v#v#v#v#v 0#v {#v :V l08,, 5 55555 05 {5 4yt= bkd8$$Ifl  @ \ xi> $*.j3@8 0{0800004 layt= s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH @`@ NormalCJ_HaJmH sH tH DA D Default Paragraph FontVi@V  Table Normal :V 44 la (k (No List 4@4 IKEHeader  !4 4 IKEFooter  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< " AAAAADI q #   d e   8@0(  B S  ?9:BCUW]t &(;=OQ]_ik~&(24G-9H_iks<FGgh|33^sHI\]^^__ccdeffgghhjklnqqyz^sHI\]^^__ccdeffgghhjklnqqyzKL2XMh88^8`CJOJQJo(qh ^`OJQJo(oh   ^ `OJQJo(h   ^ `OJQJo(h xx^x`OJQJo(oh HH^H`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(KL2         @?NkFaJ 2@<C2#6)lg+C|+1!4@A.CDIKEHhZNqNzNQ3S?VT\NV]L^r^g_Nbg]g{}ktkNUj]2l_vC@c.UOMRpe= kr3BN"u5aEi8/< c} *-@ gggg@ x@UnknownG.[x Times New Roman5Symbol3. .[x Arial;Wingdings?= .Cx Courier NewA$BCambria Math"qh‡‡X(G  !243QHP?.CD2!xx Date Robin MillerWinters, Gregory Oh+'0lp  8 D P \hpxDateRobin MillerNormalWinters, Gregory2Microsoft Office Word@@X!0@`Na@`NaGn$mVT ]7  1!.@"Arial--- +2 >0 0Annual Personal Fall     72 > 0Arrest System Inspection Form         2 > 0  0 ''  2 P 0  0 ''U)@"Arial---  2 `)U   2 nd )USerial Number   2 n)U   2 |)Uor  2 |)U   #2 \)UPerson Assigned   2 )U   2 l )UTo Use The   2 )U   2 n )UEquipment   2 )U    2 )U  'U@"Arial---@"Arial--- 2 UHarness   2 U    2 U  '8U--- 2 & U8Connecting   2 4U8Device   2 4U8    2 CU8    2 QU8  '\U8--- 2 J8U\Strap  2 J8U\    2 X8U\  'U\--- 2 |t\UPut in   2 o\UService   2 x\UDate  2 \U    2 \U  'U---  2 `U   2 nUDate of   2 | UInspection  2 |U  @Wingdings------------ 2  U(Initial and  ---------  2 U ---  2 U  2  Ufor good,  ---  2 U ---  2 U  2  Ufor poor   2  Ucondition)  2 U  'SU---  2 `*US   2 nUSDate of   2 |  USInspection  2 |GUS  --- 2  US(Initial and  ---  2 US ---  2 US  2  USfor good,  ---  2 US ---  2 US  2  USfor poor   2  UScondition)  2 FUS  'UT---  2 `}TU   2 niTUDate o 2 nTUf   2 |_ TUInspection  2 |TU  --- 2 _ TU(Initial and  ---  2 ]TU ---  2 gTU  2 j TUfor good,  ---  2 aTU ---  2 jTU  2 l TUfor poor   2 a TUcondition)  2 TU  'U---  2 `U   2 nUDate of   2 | UInspection  2 |U  --- 2  U(Initial and ---  2 U ---  2 U  --- 2  Ufor good, ---  2 U ---  2 U   2  Ufor poor   2  Ucondition)  2 U  'KU---  2 `%UK   2 nUKDate of   2 | UKInspection  2 |BUK  --- 2  UK(Initial and  ---  2 UK ---  2 UK  2 #UKfor  --- 2 UKgood, ---  2 2UK ---  2 ;UK   2  UKfor poor   2  UKcondition)  2 AUK  'UK---  2 `tKU   2 n`KUDate of   2 |V KUInspection  2 |KU  --- 2 V KU(Initial and  ---  2 TKU ---  2 ^KU  2 a KUfor good,  ---  2 XKU ---  2 aKU  2 c KUfor poor   2 XKUcondit 2 {KUion)  2 KU  'U---  2 `U   2 nUDate of   2 | UInspection  2 |U  --- 2  U(Initial and  ---  2 U ---  2 U  2  Ufor good,  ---  2 U ---  2 U  2  Ufor poor   2  Ucondition)  2 U  '- @ !U(-- @ !U(-- @ !U)- - @ !U-- @ !#U- - @ !U-- @ !#U- - @ !U7-- @ !#U8- - @ !U[-- @ !QU\- - @ !U-- @ !RU- - @ !U-- @ !QU- - @ !UR-- @ !RUS- - @ !U-- @ !WU- - @ !U-- @ !LU- - @ !UJ-- @ !QUK- - @ !U-- @ !RU- - @ !U-- @ !U- - @ !nV(- - @ !nV- - @ !nV- - @ !nV7- - @ !nV[- - @ !nV- - @ !nV- - @ !nVR- - @ !nV- - @ !nV- - @ !nVJ- - @ !nV- - @ !nV- )@"Arial--------- &2 )Date of Inspection       2 .):---  2 4)  '---  2   'S---  2 *S  'T---  2 }T  '---  2   'K@"Arial---  2 %K  'K---  2 tK  '---  2   '- @ !(-- @ !)- - @ !-- @ !#- - @ !-- @ !#- - @ !7-- @ !#8- - @ ![-- @ !Q\- - @ !-- @ !R- - @ !-- @ !Q- - @ !R-- @ !RS- - @ !-- @ !W- - @ !-- @ !L- - @ !J-- @ !QK- - @ !-- @ !R- - @ !- - @ !(- - @ !- - @ !- - @ !R- - @ !- - @ !- - @ !J- - @ !- - @ !- )@"Arial---  2 0)    2 0)  '@"Arial- - -   2   '8@"Arial- - -   2 &8  '\8---  2 [J8\  '\---  2 \  '---  2 Z  'S---  2 Z*S  'T---  2 Z}T  '@Times New Roman- - -   2 Z  'K- - -   2 Z%K  'K- - -   2 tK  '- - -   2     2     2 1    2 O    2 n    2     2     2   '- @ !(-- @ !)- - @ !-- @ !#- - @ !-- @ !#- - @ !7-- @ !#8- - @ ![-- @ !Q\- - @ !-- @ !R- - @ !-- @ !Q- - @ !R-- @ !RS- - @ !-- @ !W- - @ !-- @ !L- - @ !J-- @ !QK- - @ !-- @ !R- - @ !- - @ !(- - @ !(-- @ !(-- @ !)- - @ !- - @ !-- @ !#- - @ !- - @ !-- @ !#- - @ !7- - @ !7-- @ !#8- - @ ![- - @ ![-- @ !Q\- - @ !- - @ !-- @ !R- - @ !- - @ !-- @ !Q- - @ !R- - @ !R-- @ !RS- - @ !- - @ !-- @ !W- - @ !- - @ !-- @ !L- - @ !J- - @ !J-- @ !QK- - @ !- - @ !-- @ !R- - @ !- - @ !-- @ !- @Wingdings- - - @"Arial- - - - - - - - - - - - - - - - - -   2 0 0 - - -   2 9 0  I2 =) 0and initial to indicate good condition. - - -   2  0- - -   2   0  Y2 4 0and initial to indicate poor condition and removed f  2   0rom service.   2 ^ 0  ---  2  0  ------ M2 h, 0Inspection Criteria for PFAS per ANSI Z359.1  2 g 0- 2 k 01992- - -   2  0   2 0k 0*User must inspect before each use. Competent person (other than the user) must inspect at least annually.       2 p 0   2 0T 0*Defects, damage, inadequate maintenance shall be removed from service or undergo ad      82   0equate corrective maintenance.   2  0   _2 08 0*Inspection criteria (manufacturers instructions plus):   2 M 0  @Wingdings---@"Arial---- - - ---  2 .` 0q ---  2 .j 0 - - -  @2 .x# 0Absence or illegibility of markings   2 ., 0  0 ''---  2 <` 0q ---  2 <j 0 - - -  s2 <xE 0Absence of any element affecting the equipment form, fit, or function     2 < 0  0 ''- - - ---- - - ---  2 J` 0q ---  2 Jj 0 - - -  82 Jx 0Evidence of defects/damage to  --- 2 J! 0hardware - - -   2 JX 0:  2 J[ 0   2 J] 0c 2 Jc 0racks 2 J 0, s 2 J  0harp edges 2 J 0, d 2 J  0eformation  2 J 0, c 2 J 0orrosion 2 JI 0, c  2 JT 0hemical attack  2 J 0, e #2 J 0xcessive heating 2 J 0, a 2 J  0lteration 2 J? 0, e 2 JK  0xcessive wear   2 J 0 @ Arial---- @ !7K!- 0 ''------  2 X` 0q ---  2 Xj 0 - - -  .2 Xx 0Evidence of defects to --- 2 X  0straps/ropes- - -   2 X: 0:  2 X= 0   2 X@ 0f 2 XC 0raying 2 Xd 0, u 2 Xr  0nsplicing 2 X 0, u 2 X 0nlaying 2 X 0, k 2 X 0inking 2 X 0, k 2 X  0notting 2 X2 0, r 2 X; 0oping 2 XZ 0, b /2 Xf 0roken or pulled stitches 2 X 0, e (2 X 0xcessive elongation 2 XZ 0, c  2 Xe 0hemical attack  2 X 0, - @ !IY- 0 ''- - -   2 ex 0e 2 e 0xcessive  2 e 0  2 e 0soiling 2 e 0, a 2 e 0brasion 2 e  0, a 2 e  0lteration 2 eB 0, n 82 eN 0eeded or excessive lubrication 2 e 0, e  2 e 0xcessive aging 2 eL 0, e 2 eX  0xcessive wear   2 e 0  0 ''---  2 s` 0q ---  2 sj 0 - - -  2 sx} 0Alteration, absence of parts, or evidence of defects in, damage to, or improper function of mechanical devices and connectors     2 s 0  0 ''"Systemxm  s^3--00  //.. ՜.+,0 hp  EHSS VT  Date Title  !"#$%&'()*+,./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdeghijklmpRoot Entry FLXarData 1Tablek$WordDocument7"SummaryInformation(-pDocumentSummaryInformation8fCompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q