FSA Working at height permit {Training}

• Site conducted
  Address

• Conducted on

  Date

• Prepared by {Course code}

• Location

• Details of work to be undertaken

• Date of proposed work

  Date

• Start time

  Date

• Finish time

  Date

Work at Height Checklist (permit recipient to complete)

• Identified Entry and exit points for the work at height

  Yes

  No

  N/A

• Immediate area affected by the work at height has been barricaded and signs installed

  Yes

  No

  N/A

• Execution zone established

  Select Physical barriers Warning flagging Spotter Signage

  • Physical barriers
  • Warning flagging
  • Spotter
  • Signage

• Fall Risk controls to be implemented:

  Select Fall restraint " physical barriers" Restrain fall "Roofer kit" Limited free fall system "SRL or Lad safe system" Total free full arrest system "signal or double lanyards"

  • Fall restraint " physical barriers"
  • Restrain fall "Roofer kit"
  • Limited free fall system "SRL or Lad safe system"
  • Total free full arrest system "signal or double lanyards"

• Equipment to be used

  Select Helmet Harness Gloves Glasser A-frame ladder Extendable ladder Anchor slings Roofers kit SRL Travel system {Lad safe} Signal leg lanyard Twin hook lanyards Scaffold EWP - Scissor lift EWP - Boom

  • Helmet
  • Harness
  • Gloves
  • Glasser
  • A-frame ladder
  • Extendable ladder
  • Anchor slings
  • Roofers kit
  • SRL
  • Travel system {Lad safe}
  • Signal leg lanyard
  • Twin hook lanyards
  • Scaffold
  • EWP - Scissor lift
  • EWP - Boom

• A safety observer has been appointed where required

  Yes

  No

  N/A

• Safety observer name:

  Sign

• Work at height access equipment has been inspected and has a current inspection tag attached "Vertical adders, travel systems"

  Yes

  No

  N/A

• Work at height safety equipment has been inspected and has a current inspection tag attached

  Yes

  No

  N/A

• Permanent anchor points are suitable for the work activity, have an information plate, have been inspected and have a current test tag attached

  Yes

  No

  N/A

• Are temporary anchor points required

  Yes

  No

  N/A

• A High Risk Work Rescue Plan required

  Yes

  No

  N/A

• Additional instructions/information:

• Permit recipient name

  Sign

• Date and Time

  Date

Work party

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• I confirm that the work at height has been completed in accordance with this permit and all work is complete, all tools and equipment removed and the work area has been left in a safe condition

  Yes

  No

  N/A

• Permit recipient name

  Sign