Permit to Work - Work at Height

• Site conducted

  Select

• Document No.

All accidents are avoidable. You have a responsibility to safeguard yourself and others who may be affected by your actions. No work must take place until this Permit has been completed in full and signed by an Authorised Person.

Section1: Site and Location

• Site/Location

• Contractor

• Brief description of work

• Conducted on

  Date

• Prepared by

• Names of Engineers

Section 2: Precautions and Control Measures

• Temporary protection/barriers in place, limitations of access and warning signs in place?

  Yes

  No

• All personnel are suitably competent and trained to an acceptable standard?

  Yes

  No

• Ladders have been inspected, are in good order, correctly installed and appropriate for the works?

  Yes

  No

• Temporary plant in good working order, positioned correctly and is complete, stable and secure?

  Yes

  No

  N/A

• Protection from falling tools and materials in place? (toe-boards, tool tie-off, netting etc.)

  Yes

  No

  N/A

• Are weather conditions favourable? (dry, wind speed below 23 mph)

  Yes

  No

  N/A

• Work area clear of trip hazards and obstructions?

  Yes

  No

• Risk Assessments/Method Statements attached to Permit?

  Yes

  No

• All personnel involved understand the local Emergency Procedures?

  Yes

  No

• Client representative and any other parties that may be affected informed of work?

  Yes

  No

• Any additional information on any of the above or any other relevant issues:

Section 3: Authorisation of Permit

I declare that the above control measures are in place and communicated to the Competent Person in charge of the work

• Authorised Person:

  Sign

• Mobile Number:

• Valid From:

  Date

• Valid To:

  Date

Section 4: Acceptance of Permit by Competent Person in Charge

I acknowledge receipt of this permit and understand the safety precautions described above. I will adhere to the Method Statement and neither I, nor any person under my control will work on any other equipment. I will return this Permit to the Approved Person.

• Competent Person:

  Sign

• Mobile number:

Section 5: Time Extension (can only be granted by the Approved Person who issued the Permit)

• Authorised Person:

  Sign

• To:

  Date

Section 6: Completion of Works

I declare that the work detailed in section 1 has been completed or that no further work will take place until a new Permit is issued. The work area has been left safe, clean and tidy and equipment is safe to return to service unless otherwise stated.

• Competent Person:

  Sign

• Time/Date:

  Date

Section 7: Permit Closure

• Authorised Person:

  Sign

• Date/Time

  Date

Once the Permit has been closed, no further work activity can be undertaken and no return to high risk area is permitted.