TOOL TYPE FORM LAST REVIEWED 3/15/2014

GEOGRAPHY ALL SOURCE: HARVARD

ROOF FALL HAZARD ASSESSMENT FORM

BENEFITS
Falls are one of the leading causes of workplace injury in Canada. And falls from roofswhether during
construction of a building or while making repairsare some of the most common. To ensure that your
workers are protected from falls when working on roofs, you must assess the fall hazards posed by the work
and implement appropriate safety measures.

HOW TO USE THE TOOL

Use this form, which is adapted from one used at Harvard University, to assess the fall hazards posed by
work on a roof and ensure that the proper safety measures are used to protect workers from them. (Adapt
the form for your OHS program and operations and the fall protection requirements under your
jurisdictions OHS laws.)

OTHER RESOURCES:
Harvard Campus Services

Fall Hazards: Does Your Workplace Need a Fall Protection Plan?

Fall Hazards: Complying with the Hierarchy of Fall Protection Equipment

Fall Protection Equipment Inspection Checklist

Fall Protection Safety Video

T H I S T O O L A N D H U N D R E D S M O R E A V A I L A B L E I N T H E OHS T O O L B O X A T www.oh sin sid er .com . Templates and tools from

OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize
their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or
tools. Always consult your legal counsel and management before implementing any new policies or procedures.
 ROOF FALL HAZARD ASSESSMENT FORM
Building/location: Task:

Person completing assessment: Date:

Type of Roof Flat roof Low slope roof

Contemp. slope roof Steel slope roof
Roof Height Highest point: Lowest point:
Method of Access Stairs Ships ladder
Fixed ladder Portable ladder
Other: _________________________________________________________
Roofing Material Membrane Tar Shingles
Ballast type:_____________________________________________________
No ballast
Reason for Accessing the EQUIPMENT/DISTANCE TO EDGE
Roof Air handling unit:_________________________________________________
Chiller tower:____________________________________________________
Drains:_________________________________________________________
Heater:_________________________________________________________
Repair:_________________________________________________________
Seasonal maintenance:____________________________________________
Construction:____________________________________________________
Other:_________________________________________________________
Other Identified Hazards Low light Trip hazards
Hidden drop-offs Unstable footing
Slippery surfaces Protruding objects
Pedestrian traffic Floor openings

T H I S T O O L A N D H U N D R E D S M O R E A V A I L A B L E I N T H E OHS T O O L B O X A T www.oh sin sid er .com . Templates and tools from

OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize
their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or
tools. Always consult your legal counsel and management before implementing any new policies or procedures.
 Sloping surfaces Unstable surfaces
Skylights Moving parts
High winds Weather-related hazards (snow, ice)
Other:_________________________________________________________
Engineering Controls Guardrail system or parapet
Ladder cages
Fence
Roof anchor
Other:_________________________________________________________
Administrative Controls Boundary line system
Marked minimum distance from edge
Control zones
Safety monitors
Other:_________________________________________________________
Fall Protection Required Full body harness Boatswains chair
Web lanyard Retractable lifeline system
Travel restraint system Safety nets
Cable positioning lanyards Rope lanyards
Rope grabs Rail system
Shock absorbers
Other:_________________________________________________________
Comments:

Supervisor:___________________________________________ Date:_______________________________
OHS Department:______________________________________ Date:_______________________________
T H I S T O O L A N D H U N D R E D S M O R E A V A I L A B L E I N T H E OHS T O O L B O X A T www.oh sin sid er .com . Templates and tools from
OHS Insider are provided for members of our service. Members may use this document as is or as a starting point to customize
their own documents. OHS Insider assumes no responsibility for the effectiveness or legality of any of its online templates or
tools. Always consult your legal counsel and management before implementing any new policies or procedures.