PC HS 24 - Ladder Permit

• Site conducted

  Select

• Permit reference number:

• Nature of Works

• Exact work location
  Address

• Date Permit Issued

  Date

• Work to be carried out by: (name all workers)

• Confirm that there is a risk assessment and method statement specifically covering the tasks involved and the location

Part 2 - Precautions

• To be completed by the authorised permit issuer after obtaining confirmation of precautions from the work supervisor

• Is the ladder fit for purpose

  Yes

  No

  N/A

• All operatives must be trained in working at height?

  Yes

  No

  N/A

• Ladders must be set on level ground

  Yes

  No

  N/A

• Ladders must be tied off

  Yes

  No

  N/A

• All ladders will have a pre use inspection carried out before use

  Yes

  No

  N/A

• Work height required

• Ladder length used?

• Only 1 person on ladder at anytime

• 3 points of contact must be maintained at all times

  Yes

  No

  N/A

• Must be used for short duration only

  Yes

  No

  N/A

• If task takes longer, other means of working at height must be taken into consideration

  Yes

  No

  N/A

• A copy of this permit has been provided to staff involved in the work.

  Yes

  No

  N/A

• To be completed by the authorised permit issuer after obtaining confirmation of precautions from the work supervisor. The ladder is fit for purpose.

  Sign

Part 3 - Authorisation - to be completed by the authorised permit issuer

• I authorise the work to be carried out and have notified the relevant personnel.

  Sign

• Permit Commenced:

  Date

• Permit Valid until:

  Date

Part 4 - Acceptance - to be completed by person in charge of the work

• I’ve read and understood the conditions of this permit and am familiar with the risk assessment for the work. I accept responsibility for undertaking the work specified above in a safe manner. I declare that neither I nor those persons within my control will attempt any tasks other than those specified in this permit to work and any associated safe system of work.

• Person in charge of work

  Sign

Part 5 - Cancellation - to be completed by person in charge on the work

• I certify that the work has been completed and the work area left in a safe condition

  Sign