On-Site Rescue Plan
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1
2ON-SITE RESCUE PLAN
Confined Space Name/Location:
Identification #:
Date:
Attendant:
Employer:
Employer: _________________________________________ 2) _________________________________________________
On-Site Rescue Personnel/Designation:
3) _________________________________________________
1) ________________________________________________
4) _________________________________________________
Methods of Communication: Attendant to Rescue Personnel:- O Phone
O Audible Signal
O Radio
O Intercom
Attendant to workers: O Phone
O Radio
O Intercom
O Audible Signal
O Visual Hand Signal
O Rope Signal
Methods of Rescue: O External (Retrieval)
O Internal: _____________________
O Congested: ______________________
O Hauling System Required: __________________ O Patient lowering system required/lowering area: ______________________
O Anchor overhead: ________________________________________________________________________________________
Anchorage:
O Beam
O Stairwell
O Support Strut
O Support Column
O Other: ______________________________
Pre-Rigging required? O Yes
O No
Rescue Equipment Requirements (check a where applicable below and indicate quantity needed):
O Hauling Systems:_____
O Carabiners: _____
O Pulleys: _____
O Shock absorbers/lanyards: _____
O Anchor Straps: _____
O Webbing: _____
O Ascenders: _____
O Body Harnesses: _____
O Rigging Plates: _____
O Safety Lines: _____
O Main Lines: _____
O Wrist/Ankle Harnesses: _____
O Fire Extinguishers: _____ O
O
O
Rescue Equipment Inspections
Identified rescue equipment inspected by competent worker: _____________________ Employer: ________________________
Record of inspection(s) attached
O Yes
Medical Equipment Requirements (check a where applicable below and indicate quantity needed):
O First Aid Kit: _____
O Packaging Device: _____
O
O
Additional PPE Requirements (Indicate what is needed):
O High Visibility Vests O Hearing Protection O Safety Boots O Hard Hats O Safety Glasses/Goggles O Gloves
O Face Shield
O
O
Description of Space (include location of attendant):
Diagram of Space (Use Back of Page if needed):
Completed by: ______________________ O Entry Supervisor
O Attendant
O Other: ____________
Date:
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Parent category: Business