PDI Safety

Date Prepared *

Project / Job Name *

Submitted By

Site-Specific Fall Protection Plan

Use this form only when the preferred hard barricade, guardrail, fence, or continuous perimeter barrier cannot be used for the specific work setup. The completed plan must prove why the preferred control is not feasible and how the selected fall restraint setup eliminates the fall hazard by preventing workers from physically reaching the trench edge.

Project Location *

Job Number

Plan Prepared By

Competent Person On Site *

Site-Specific Barricade Infeasibility

Do not use this section to justify convenience. Document the actual site condition, work step, access point, equipment movement, or material-handling conflict that prevents a hard barricade from working as the direct control.

Why a hard barricade is not feasible for this setup *

Hard barricade would block shoring, shield, or wall setup/removal.Hard barricade would block ladder placement, edge access, or safe access/egress setup.Hard barricade would block lowering trench plates, trench boxes, conduit, cable, tools, or supplies.Hard barricade would prevent the trench-edge work that requires the excavation to exist.Hard barricade would have to be repeatedly removed/reinstalled, creating a false-security cycle and repeated exposure.Site geometry, equipment movement, or available work area prevents an effective hard-barricade layout.Other site-specific condition documented below.

Site-Specific Infeasibility Explanation *

Why Fall Restraint Provides Equal or Better Protection *

Fall Restraint Setup

PDI uses fall restraint as a direct control for this setup. The fall hazard is eliminated from the worker's position when the anchor setback and lanyard length prevent the worker from physically reaching the trench edge.

Trench Depth (ft) *

Soil Classification *

Minimum Anchor Setback (ft) *

Restraint Lanyard Length (ft) *

Trench is deeper than 10 ft, Type C/wet, or unusual soil conditions require an engineered anchor and setback plan.Fall arrest is required because restraint cannot prevent the worker from reaching the edge.

Plan Acknowledgment Names

Photo Documentation

Tip: “Upload from Photos” pulls a photo your camera app already saved to the device. “Capture in app” attaches to this record but may not also save to your album.

No photos attached yet

plan setup overview

Upload from PhotosUse Camera

anchor setback

Upload from PhotosUse Camera

trench edge / access

Upload from PhotosUse Camera

harness and lanyard

Upload from PhotosUse Camera

Additional / Other Photos

From PhotosCapture in app