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Self Retracting Device Inspection Form
Manufacturer:
*
Owner/Company:
*
Model:
*
Description:
Serial:
*
Lot:
*
Date of Manufacture:
*
Length:
Lifeline Material:
Web
Stainless steel
Galvanized steel
Labels & markings
Label (Intact & Legible)
Pass
Fail
N/A
Appropriate ANSI/OSHA/CSA Markings
Pass
Fail
N/A
Inspections are Current / Up-to-Date
Pass
Fail
N/A
Date of First Use
Pass
Fail
N/A
Shock pack (if present)
Cover / Shrink Tube (Don’t Cut or Remove)
Pass
Fail
N/A
Damage / Fraying / Broken Stitching
Pass
Fail
N/A
Impact Indicator (Signs of Deployment)
Pass
Fail
N/A
Housing
Attachment Point
Pass
Fail
N/A
Nuts / Bolts / Rivets / Screws
Pass
Fail
N/A
Evidence of Damage (Dents/Cracks/Rust)
Pass
Fail
N/A
Lifeline (web or Cable)
Termination (Stitch, Splice, or Swage)
Pass
Fail
N/A
Cuts / Fraying / Broken Stitching
Pass
Fail
N/A
Excessive Wear
Pass
Fail
N/A
Cable Separating / Bird-Caging
Pass
Fail
N/A
Entire Length Retracts Smoothly
Pass
Fail
N/A
Test Braking / Locking Function
Pass
Fail
N/A
Stitching
Connectors
Pass
Fail
N/A
Impact Indicator
Pass
Fail
N/A
Hook Body / Rivets
Pass
Fail
N/A
Corrosion
Pass
Fail
N/A
Pitting / Nicks
Pass
Fail
N/A
Notes:
Foreman Name:
Project Name:
Name of Inspector:
*
Date of Inspection:
*
Employee ID:
*
In-Service Date:
Print Name:
*
Signature:
*
Clear Signature
Upload Files :
Foreman Email:
Other Email:
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