All Operating Guidelines have been reviewed and approved by the Technical High Angle Rope Rescue Steering Committee.

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1 SAMPLE FORMS FORMS FIRE DEPARTMENT FORMS INDEX Fire Service Application For Technical Rescue Service (ADM2) Fire Chief s Training Equivalency Sign-off Sheet (ADM3) Application for Initial Purchase and Reimbursement of Authorized Equipment Packages (FIN1) Application for Reimbursement of Department Expenses (FIN2) Application for Annual Stipend & Reimbursement for Tower Crane Site Inspections (OPS2) All Operating Guidelines have been reviewed and approved by the Technical High Angle Rope Rescue Steering Committee. TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES FORMS Issued 22DEC00 Revised 09NOV12 Page 1 of 1

2 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM FIRE SERVICE APPLICATION FOR TECHNICAL HIGH ANGLE ROPE RESCUE SERVICE We, the undersigned, being authorized representatives of the business named herein (hereinafter referred to as the Company ), and contributors to the funding of the Fire Service Rope Rescue Program (hereinafter referred to as the Service ), hereby request said Service for the duration of the Company s construction project indicated below. The Company acknowledges and understands that eligibility for, and access to the Service shall remain contingent upon the Company s continuing compliance with the prerequisite Terms and Conditions of Service defined in this document. The Company further acknowledges that from time to time, authorized representatives of the Service reserve the right to verify the Company is in compliance with the Terms and Conditions of Service and agree to cooperate with the representatives during such verifications. The Company fully understands that failure to comply with the Terms and Conditions of Service may result in termination of Service, which may result in the Company being in contravention of Workers Compensation Board s Occupational Health and Safety Regulation. Tower Crane Technical High Angle Rope Rescue Service or Service is understood to mean Command and execution of a rope rescue by a Fire Department and does not imply any guarantee of the success of a rescue. TERMS AND CONDITIONS OF SERVICE 1. The Company shall ensure that the information contained herein is communicated to all persons employed by the Company who are, or may become responsible for, the establishment and maintenance of the Terms and Conditions below. 2. The Company shall ensure that a facility at, or on, the project named herein, has been designated as the Fire Service Technical Rescue Command Post, and has been appropriately identified and equipped with signage acceptable to the representatives of the Service. 3. The Company shall designate one (1) liaison person from the head office, to whom the Service shall have reasonable access on a twenty-four (24) hour basis, and two (2) liaison persons at the project site to whom the Service shall have immediate access to during normal business hours and on-call access on a twenty-four (24) hour basis. Portable communication devices to be utilized shall be acceptable to the representatives of the Service. 4. The Company shall provide to representatives of the Service a plot plan of the project complete with the street address, on which shall be identified the Service s staging area, access routes to the site, temporary structures and utilities, locations and particulars of where a rescue may need to be performed. 5. The Company shall ensure the access point and staging areas are maintained in such a fashion as to accommodate the requirements of the vehicles, materials and equipment of the Service. The Company shall immediately notify the Service of any deviation from this requirement that may affect the response time of the Service. 6. If, upon a site survey, a Fire Department identifies a need for special or extra equipment out of the ordinary, a Department representative should contact the BCCSA THARR Program Representative at or [email protected]. TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES ADM 2 Issued 20APR98 Revised 09NOV12 Page 5 of 7

3 2014 Fire Service Application For Tower Crane Technical High Angle Rope Rescue Service Company Name Company Address Company Liaison Name Position (day) (evening) Pager/Cell Project Name Project Address Project Liaison Name Position (Primary) (day) (evening) Pager/Cell Project Liaison Name Position (Secondary) (day) (evening) Pager/Cell Anticipated service requirement end date Type of Request (please check) first site survey 2 tower cranes second site survey due to relocation of crane on the site or annual site survey on long-term project Other Name on Crane (e.g. A, B ) Name on Crane (e.g. A, B ) Name on Crane (e.g. A, B ) Name on Crane (e.g. A, B ) Please explain The crane(s) will be available on the following date(s) for fire department training *Please note this form must be completed in its entirety. We, the undersigned, being authorized representatives of the Company and the Fire Service, agree to the Terms and Conditions of Service and additional requirements stated herein. A copy of this application and the Terms of Conditions have been received by the Company. The Company shall be eligible for Service as of this date. FOR THE COMPANY Representative Name and Title (please print) Signature FOR THE SERVICE Representative Name and Title (please print) Signature DATED this day of 20 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES ADM 2 Issued 20APR98 Revised 09NOV12 Page 6 & 7 of 7

4 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM Fire Chief s Training Equivalency Sign-off Sheet The following checklist must be completed by a Program funded Fire Department s Fire Chief and submitted to the BCCSA THARR Program Representative with requests for reimbursement of training in Awareness, Level I & Level II courses. NOTE This checklist applies to Awareness, Level I & Level II through qualified in-house trainers or third party training provider. Please check the appropriate course box(s), as may apply in this circumstance. Please refer to ADM1 page 3 of 4 for training standards as per Minister s Order. Candidate s Name Rank (Please Print) (Please Print) AWARENESS NFPA, 1670, Awareness Implementation of the emergency response system NFPA 1983 Edge safety (low (10 to 40 ) and steep (40 to 60 ) angle embankment) History of NFPA Personal safety Recognition of a technical rescue History of rope incident. Scene management Knots, bends & hitches Equipment safety and inspection Identification of software & hardware Types of rope (strengths & Identification of stretchers & packaging devices weaknesses) WCB Regulations Section s 11 & 32 Identification & donning of harnesses Personal Protective Equipment Placing attendants for low and steep angle rescue Simple anchoring & rigging (bomb Patient packaging for low & steep angle rescue proof) Hand signals & communication (lowering, rappelling, haul team) Rappelling (main line attachment, safety line attachment, self rescue & bottom belay) Simple mechanical advantage (3-1, 4-1, 5-1, 3-1 Z-Rig) TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES ADM 3 Issued 02MAY00 Revised 09NOV12 Page 2 of 3

5 Level I NFPA 1006, 1670 Level I Advanced knots, bends, hitches and load releasing hitches NFPA 1983 Raising vertical & horizontal baskets Identification of Software and their Ascending and descending a rope properties Identification of Hardware and their properties Edge management (protected edge, unprotected edge) Pick-off of patient Simple and compound mechanical advantage systems Line transfer of patient (two methods) Lowering vertical/horizontal baskets (high &low point) Patients packaging (horizontal, vertical, bee suit, wrap evac, webbing) Level II NFPA 1006, 1670 Level II Lowering & raising with knot passing NFPA 1983 Lowering and raising with attendants Advanced line transfers Positioning attendants Advanced anchoring systems (pre tensioned back ties, load sharing, multiple anchors, critical angles) Compound & complex mechanical advantage (effects of load multipliers, calculating loads & forces) Selecting, constructing and using a highline rope system Selecting, constructing and using a sloping highline rope system Selecting, constructing and using a drooping highline rope system Selecting, constructing and using an English Reeve highline rope system I hereby verify that our Department s employee (The Candidate) named above, has successfully completed the training programs I have indicated, and I am fully satisfied that the content of this training satisfies the NFPA standards specified. Name of Training Agency Fire Dept Date Fire Chief Fire Chief (SIGNATURE) (PLEASE PRINT NAME) TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES ADM 3 Issued 02MAY00 Revised 09NOV12 Page 3 of 3

6 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM APPLICATION FOR INITIAL PURCHASE AND REIMBURSEMENT OF AUTHORIZED EQUIPMENT PACKAGE(S) 1. This application for equipment package(s) must follow successful completion of all courses that comprise the Technical High Angle Rope Rescue Program by at least one instructor. 2. Upon approval of this application, purchase your equipment and submit original receipts and, invoice(s) for authorized items purchased. A reimbursement cheque will be sent to you. Fire Department Address Telephone Contact Person Name(s) of Qualified Instructor(s) Request for equipment package(s). Please send to Technical High Angle Rope Rescue Program BC Construction Safety Alliance 400, 625 Agnes Street New Westminster, BC V3M 5Y4 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES FIN 1 Issued 20APR98 Revised 12DEC11 Page 3 of 6

7 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM APPLICATION FOR REIMBURSEMENT OF DEPARTMENT EXPENSES 1. Department Information Fire Department Mailing Address Telephone Contact Person 2. Indicate [ ] the course your department candidate(s) successfully completed, on which this claim is based Course Course Maximum Fees Curriculum Curriculum [ ] Awareness Level [ ] Instructor Training [ ] Level I [ ] Tower Crane Rescue Training $ (combined) [ ] Level II [ ] * Refresher /Level II/Tower Crane $ Candidate(s) Name(s) and Course(s) Particulars Please Print All Information (invoices required) Department Candidate Name(s) Course Name(s) Dates Attended Course Fee(s) Claimed 1. $ 2. $ GST $ TOTAL COURSE FEES CLAIMED $ 4. Backfill or Days Off Expenses (if more space required please submit on separate sheet) Backfill Name(s) or Candidate Name (s) Backfill Rank(s) Dates Worked Hours x Rate = Amounts 1. $ $ 2. $ $ TOTAL BACKFILL COSTS CLAIMED $ 5. Candidate(s) Accommodation Expenses Options Hotel = H for $ (receipts required); or Private = P for $35.00 (no receipt required) Department Candidate(s) Enter H or # of Nights x Rate = Name(s) P Amounts 1. $ $ 2. $ $ GST $ PST $ TOTAL ACCOMMODATION EXPENSES CLAIMED $ TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES FIN 2 Issued 23MAR99 Revised 12NOV13 Page 5 of 7

8 6. Candidate(s) Daily Meal Expense(s) B=$13.50, L=$15.50, D=$25.50 = $54.50/day(no receipt required) Lunch only for GVRD Departments Department Candidate(s) Name(s) Dates Meals Claimed # of Meals Claimed (i.e. 1B+2L+3D) 1. $ 2. $ TOTAL MEAL EXPENSES CLAIMED $ Total $$ Amounts 7. Candidate(s) Travel Expense(s) - AIR (Per Published Government Rates) (receipts required) Department Candidate(s) To From Travel Carrier Used Fare Name(s) Dates 1. $ 2. $ GST $ TOTAL ROUNDTRIP (RT) AIR TRAVEL EXPENSES CLAIMED $ 8. Candidate(s) Personal/Dept. Vehicle Roundtrip (RT) Wheels-Turned Mileage choose from a) or b) Department Candidate(s) Name(s) a) Home Dept.- Course Site OR b) Daily RT Kms x Crse Days x $0.52 H, P Accom. or Total $$ Amounts 1 x RT Kms x $0.52/km Residence to Crse 1. $ 2. $ TOTAL WHEELS-TURNED MILEAGE EXPENSES CLAIMED $ 9. Candidate(s) Vehicle Rental/Taxi/Ferry/Other (specify) (receipts required) Total Department Candidate(s) $$ Name(s) Amounts 1. $ 2. $ GST $ PST TOTAL VEHICLE/TAXI/OTHER EXPENSES CLAIMED $ Upon Completion Return to Technical High Angle Rope Rescue Program BC Construction Safety Alliance 400, 625 Agnes Street New Westminster, BC V3M 5Y4 TOTAL AMOUNT GST THIS CLAIM $ TOTAL AMOUNT PST THIS CLAIM $ TOTAL AMOUNT THIS CLAIM $ FIRE CHIEF OR SIGNING AUTHORITY (Signature) (Authority s Printed Name) Please read FIN2 for clarification of reimbursement allowances. Incomplete applications will be returned to the submitting Fire Department. TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES FIN 2 Issued 23MAR99 Revised 12NOV13 Page 7 of 7

9 TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM APPLICATION FOR ANNUAL STIPEND & REIMBURSEMENT FOR TOWER CRANE SITE SURVEYS Request for Calendar Year 20 (completed calendar year) Fire Department Fire Chief or designate ANNUAL STIPEND On behalf of our fire department, I am making application for the annual stipend in the amount of $ (covering the recently completed calendar year) as allowed for by our participation in the Technical High Angle Rope Rescue Program. I have included the required statistical report for rope rescue services and training within our jurisdiction. TOWER CRANE SITE SURVEYS I am also making application for reimbursement of (number) tower crane site surveys at $ per survey for a total of $. I have enclosed copies of signed Technical High Angle Rope Rescue Program Fire Service Application For Technical High Angle Rope Rescue Service as evidence of these site surveys. Please make cheque payable to Address VERIFICATION OF SERVICE & TRAINING This will also verify that this fire department intends to continue providing THARRP service in the coming year and that THARRP funded instructors will conduct inhouse training to applicable NFPA Standards as per the THARRP Operating Guidelines. Dated Signed Our records show that funded instructors for your department are as follows If your records do not agree with this listing, please contact the THARRP Representative at TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES OPS2 Issued 23JUN98 Revised 09NOV12 Page 4 of 6

10 A fire department will not qualify for the annual stipend if this form is not fully and accurately completed. Technical High Angle Rope Rescue Program Operating Guidelines OPS2 Issued 23JUN98 Revised 09NOV12 Page 5 of 6 Technical High Angle Rope Rescue Statistical Report PLEASE SEE INSTRUCTIONS ON THE FRONT OF THIS FORM PLEASE PRINT CLEARLY FIRE DEPARTMENT CALENDAR YEAR TRAINING CONDUCTED Total Rope Rescue Training Hours **** RECORDED BY Dec (prior year) Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Totals WORK SITE RESCUES (Enter number) SITE SURVEYS COMPLETED (Enter number) ***Please see instructions on the opposite side of this form.

11 TECHNICAL HIGH ANGLE ROPE RESCUE STATISTICAL REPORT - INSTRUCTIONS 1. Print name of the City/Town/Municipality for which the statistics apply in the box titled FIRE DEPARTMENT. 2. Print the name of the person recording this information in the box titled RECORDED BY. 3. In the matrix titled TRAINING CONDUCTED, enter the Total Rope Rescue Training Hours. Do not include initial Instructor Course training time in this report. To calculate the Total Rope Rescue Training Hours - take the number of hours for each training session - multiply this by the number of trainees participating in each session - this total is the Total Rope Rescue Training Hours - repeat this for each training session - determine the Monthly Total by adding up the Total Rope Rescue Training Hours for each training session that occurred in the month - if no training hours have been completed leave the field blank For example If in January you had three (3) training sessions. The first session lasted two (2) hours, and had 25 participants, the second session lasted eight (8) hours, and had ten (10) participants, and the third session lasted four (4) hours, and has 12 participants. Session One 2 hours X 25 trainees = 50 person hours Session Two 8 hours X 10 trainees = 80 person hours Session Three 4 hours X 12 trainees = 48 person hours January Total Rope Rescue Training Hours = In the matrix titled WORK SITE RESCUES, enter the number of rescues performed on a work site (do not include wilderness rescues for example). 5. In the matrix titled SITE SURVEYS COMPLETED, enter the number of tower crane site surveys conducted. This number should correspond with what is recorded on the TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM APPLICATION FOR ANNUAL STIPEND & REIMBURSEMENT FOR TOWER CRANE SITE INSPECTIONS form. Record the site surveys by month. 6. Submit the completed form, via mail, or fax on or before December 15 th, to Technical High Angle Rope Rescue Program BC Construction Safety Alliance 400, 625 Agnes Street New Westminster, BC V3M 5Y [email protected] Fax TECHNICAL HIGH ANGLE ROPE RESCUE PROGRAM OPERATING GUIDELINES OPS2 Issued 23JUN98 Revised 09NOV12 Page 6 of 6