Culligan Work at Height (WaH) Permit

• Date the task is taking place (Permit Valid for 24 hours)

  Date

• Prepared by

• Location
  Address

• What is the task? (Brief description of the work taking place).

• What is the name of the contractor?

Equipment used

Inspection

• Is the contractor performing the task approved and on the suppliers database?

  Yes

  No

• Address issue with purchasing department.

  Select Issue addressed with purchasing dept

  • Issue addressed with purchasing dept

• Name of the site workgroup manager/supervisor?

• What is the site workgroups manager/supervisors telephone number?

• All the members of the workgroup site inducted?

  Yes

  No

• Perform Contractor Induction and retain evidence.

  Complete

• Are the worker(s) qualified and have all related licences/skills cards been witnessed such as an IPAF 3a/3b licence, in date and evidence taken?

  Yes

  No

• What evidence do they have to show they are competent to perform the task?

• Risk Assessment/Method Statement received and approved

  Yes

  No

• Review risk assessment and ensure all precautions stated are in place before work commences and attach RAMS as .pdf

• Attach the approved RAMS

Significant Hazards and Control Measures . (See Risk Assessment and Method Statement for full details)

• Type of working at height

  Select Racking Build/Inspection/Repair Roof/Guttering Inspection/Repair Construction Other Inspections/Repair

  • Racking Build/Inspection/Repair
  • Roof/Guttering Inspection/Repair
  • Construction
  • Other Inspections/Repair

• Hazards

  Select Fall of a person(s) from height Fall of tools/work materials Weak Roof Impact injury for those working below Inappropriate equipment

  • Fall of a person(s) from height
  • Fall of tools/work materials
  • Weak Roof
  • Impact injury for those working below
  • Inappropriate equipment

• Precautions

  Select Work area cordoned off Staff working below wearing helmets/bump caps PPE - Fall arrester (Harness/Lanyard) have thorough examinations dated within last 6 months. Tools tethered with lanyards Safe Access and Egress provided for other work groups. Other

  • Work area cordoned off
  • Staff working below wearing helmets/bump caps
  • PPE - Fall arrester (Harness/Lanyard) have thorough examinations dated within last 6 months.
  • Tools tethered with lanyards
  • Safe Access and Egress provided for other work groups.
  • Other

• Please describe

• Fall Prevention/Arrest needed?

  Yes

  No

Equipment

• Are you using any of the following

  Select MEWP (Scissor lifts/Cherry Pickers/Genie Booms) Ladder Scaffold Step/Platform Ladder None

  • MEWP (Scissor lifts/Cherry Pickers/Genie Booms)
  • Ladder
  • Scaffold
  • Step/Platform Ladder
  • None

• What is the date of the last thorough examination (Must be within last 6 months)

  Date

• When was the Scaftag last signed by a competent person (Must be within last 7 days or earlier if involved in incident).

  Date

• What is the construction type and when was the ladder last inspected? (Note Wooden ladders are not allowed. Metal ladders are only allowed for none electrical works)

• What is the construction type and when was the ladder last inspected? (Note Wooden ladders are not allowed. Metal ladders are only allowed for none electrical works)

• Are you working outside

  Yes

  No

• Are the current conditions and forecast suitable for the type of work.

  Select Suitable - Ok to proceed Not Suitable - Stop work and wait for improvement

  • Suitable - Ok to proceed
  • Not Suitable - Stop work and wait for improvement

• Does the task require electrical/Hot work?

  Yes

  No

• Additional permits are required to assess the electrical/ hot work

• You must complete aditional permits (183a Electrical/183b Hot Work)

  Complete

• Are there other work activities in the area

  Yes

  No

• Have they been informed and to keep clear and is signage in place as a reminder?

  Confirmed

1st Aid Arrangements

• What are your First Aid Arrangements?

  Rely on business First Aiders

  Own First Aider

• Have the First Aid team been made aware of your work on site?

  Yes

  No

• Raise action to ensure first aiders informed of work on site

• Please add your first aider information

• Working at height rescue plan required

  Yes

  No

• Does this form part of your risk assessment?

  Yes

  No

• Review your risk assessment and include details of your rescue plan

Waste Disposal

• Are you generating wastes as part of your task?

  Yes

  No

• How are you disposing of the waste

  Select on site waste arrangements (Segregation required) Own arrangement (Advise waste carrier's name)

  • on site waste arrangements (Segregation required)
  • Own arrangement (Advise waste carrier's name)

• Name of waste carrier arranged to collect waste

Authorisation and Acceptance

• On behalf of the business, I authorise the work to be undertaken having personally examined the work site and all the documentation to confirm the precautions taken are adequate and conform to the business EHS Policy

• Issued by:

• Authorised Signature

  Sign

• On behalf of the workgroup , I have personally examined the work location and have read and understood this form. I undertake to ensure that all works are carried out in accordance with this permit and EHS Policy.

• Contractor Supervisor/Manager

• Authorised Signature

  Sign

End of day. Worksite safe handover declaration.

• Work day complete?

  Yes

  No

• Work progressing as per the job order. All work materials, wastes and equipment have been removed. Any isolations and lock out tags have been removed and services restored. The area is safe to recommence normal working activities

  Yes

  No

• Confirmed by the contractor

• Authorised Signature

  Sign

• Witnessed by

• Any final remarks/comments

  Yes

  No

• Your remarks

• Go to Job completion declaration

Job Completion Declaration

• Task Complete?

  Yes

  No

• Work completed to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations and lock out tags have been removed and services restored. The area is safe to recommence normal working activities

  Yes

  No

  N/A

• Confirmed by the contractor

  Sign

• Authorised Signature

  Sign