Demo One DOA-21 Ladder-Stepladder Permit to Use

• Project Number

• Site Specific Location of Work for Permit Use

• Work Description

• Site Address
  Address

• Date

  Date

• Prepared By

• PLEASE NOTE: This Permit, which must be signed, briefed and approved prior to the work, is to be used when operatives are required to use ladders/stepladders where an approved conventional fall protection system is either not practical or creates a greater hazard.
  
  ZERO HARM
  

  

LADDER/STEPLADDER PERMIT TO USE JUSTIFICATION

• Describe the reason a ladder/stepladder is necessary

• Is the works internal or external?

• Internal

• Please detail ground surface conditions

• External

• Please detail ground surface and weather conditions

SELECT THE CONTROLS TO BE USED TO REDUCE THE FALL HAZARD

• Tick one or more

  

• Safety Monitor Assigned*

• *The role of a Safety Monitor will be to stabilise the ladder/stepladder during use, and communicate verbal warnings to the user of recognised fall hazard conditions

• 3-Point Contact Maintained During Performance of Task

• Ladder Secured to a Fixed Object

• Short Duration Task (<20 minutes)

• Light Duty Task (material being handled weighs <3 kg)

• Use of Special Instructions

• Please Describe

• Selection of Special Work Methods

• Please Describe

AFFECTED OPERATIVES WHO HAVE RECEIVED A BRIEFING ON THE COMPLETED PERMIT

• Name and Signature of Operative 1 Performing the Task

  Sign

• Name and Signature of Operative 2 Performing the Task

  Sign

• Name and Signature of Operative 3 Performing the Task

  Sign

• Name and Signature of Operative 4 Performing the Task

  Sign

• Name and Signature of Operative 5 Performing the Task

  Sign

APPROVAL

• Prepared and Approved by Site Supervisor

  Sign