Title Page
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Document No
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Site conducted
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Conducted on
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Prepared by
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Issuing Permits – The issuing of permits is strictly controlled; permits can only be issued by competent persons
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Project & Job Location:
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Work Description:
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Approx. maximum height of the task
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Justification for Use of Steps/Ladder
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Describe (in detail) the reason safer means of access can’t be used?
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Is a suitable and sufficient risk assessment completed?
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Is a method statement applicable?
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Has the requester inspected the area prior to commencement of the task?
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Other Controls to the Reduce the Fall Hazard
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(Please document additional control measures)
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Height/size of Ladder/Step to be used:
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APPROVALS
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Requested By: Print Name
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Date
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Signature
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Operative: Print Name
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Signature
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Approved By: Print Name
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Date
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Signature
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Closed out by: Print Name
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Ladder MUST be returned by end of shift
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Date
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Signature
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To:
