Permit to Work - Working at Height

• Audit Category

  Select

• Audit Title

  Select

• Conducted on

  Date

• undefined

• Plant/Equipment Name

• Work at Height ID

• Location of Work

• Description of Work

• Date of Work

  Date

• Expected duration of Work

• Working on Roof

  Yes

  No

• Please Read SOP

• SOP Available

  Yes

  No

• Please Fill JSEA

  Yes

  No

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Weather Conditions are suitable for Work

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Lighting Conditions adequate

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• All persons have completed working at height training

  Yes

  No

• Suspend Permit, Please check with Permit Issuer/ Manager

• Harness/fall restraints inspected/tagged in date

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• The work area below barricaded to prevent falling object risk

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Roof anchor points inspected in date

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Working on Ladder

  Yes

  No

• Please Read SOP

• SOP Available?

  Yes

  No

• Please Fill JSEA

  Yes

  No

  N/A

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Weather Conditions are suitable for Work

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Lighting Conditions adequate

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All persons have completed working at height training

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• The work area below barricaded to prevent falling object risk

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Area is clear of overhead electrical hazards

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Pedestrian access to work are appropriately restricted

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Ladders are AS stamped, in good condition and are appropriate

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Ladders are appropriated for the task and pre-inspected

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Ladder is secured appropriately

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Operating Scissor Lift

  Yes

  No

• Please Read SOP

• SOP Available?

  Yes

  No

• Please Fill JSEA

  Yes

  No

  N/A

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Weather Conditions are suitable for Work

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Lighting Conditions adequate

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• A pre-start checks of safety equipment completed

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All persons have completed working at height training

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• The work area below barricaded to prevent falling object risk

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Pedestrian access to work are appropriately restricted

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Area is clear of overhead electrical hazards

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Operating Boom Lift

  Yes

  No

• Please Read SOP

• SOP Available?

  Yes

  No

• Please Fill JSEA

  Yes

  No

  N/A

• Job Details

• Location of Work

• JSEA Developed by

  Sign

• Date

  Date

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Personnel Involved in Activity

  Yes

  No

  N/A

• Name of Relevant Worker

• Qualification / Licenses / Ticket Held

• Signature

  Sign

• Common Hazards

  Yes

  No

• Work Environment/Site Layout

• Working from Height

• Ground Surface

• Stability

• Security

• Vibration

• Confined Spaces

• Site Access/Egress

• Underground Hazards

• Lighting

• Mobil Plant/Pedestrians

• House Keeping

• Asbestos

• Thermal Comfort

• Slips & Trips

• Overhead Hazards

• Site induction

• Chemical

• Biological

• Fire/Flammability

• Corrosive

• Compatibility

• Labelling

• MSDS Available

• Absorption

• Inhalation/Ingestion

• Signage

• Spill Control

• Storage

• PPE Available

• Manual Handling

• Repetitive Actions

• Cold/Hot

• Lifting/Carrying

• Bending/Reaching

• Excessive Distances

• Awkward Postures

• High Forces- Heavy Load

• Pushing/Pulling

• Restraining/Supporting

• Stability/Size of Load

• Plant

• Crushing

• Cutting/Stabbing

• Electrical

• Entanglement

• Falling

• High Pressure

• Hot Surfaces

• Isolation

• Maintenance

• Noise

• Pre-start Checks

• Striking

• Signage

• Safe Work Procedures

RISK MATRIX

• HSW RISK MATRIX

JOB SAFETY ANALYSIS

• Job Safety Analysis

  Yes

  No

  N/A

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• Task

• Hazards

• Potential Risk Score

• Risk Control Measures

• Residual Risk Score

• Responsible Person

  Sign

• A pre-start checks of safety equipment completed

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Weather Conditions are suitable for Work

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Lighting Conditions adequate

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Structure/Work area has been inspected and assessed as safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Work platform inspected and assessed as operational and safe

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Appropriate EWP licenses sighted

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Harness/fall restraints inspected/tagged in date

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• The work area below barricaded to prevent falling object risk

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Pedestrian access to work are appropriately restricted

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• All persons have completed working at height training

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Area is clear of overhead electrical hazards

  Yes

  No

  N/A

• Suspend Permit, Please check with Permit Issuer/ Manager

• Are you using tools/Equipment at Height?

  Yes

  No

• Isolation Required

  Yes

  No

• Electrical

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Pneumatic

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Hydraulic

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Stored Energy (Compressed Spring, Compressed Air, Hydraulic Pressure, Fluid Pressure)

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Fluid (Chemical, CIP, Product, Hot Water, Cold Water)

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Isolation Required

  Yes

  No

  N/A

• Employee Name

• Plant/Equipment Name

• Time Locks were attached

  Date

• Time Locks were removed

  Date

• Signature

  Sign

• Rescue Plan Required

  Yes

  No

• Rescue Type

  Assisted Rescue

  Emergency Services

  Self Rescue

• Name of stand by First Aider

• Communication Arrangements

• Description of Plan

• Emergency Equipment

  Yes

  No

  N/A

• Fall Arrest

  Yes

  No

  N/A

• Torch

  Yes

  No

  N/A

• Fire Extinguisher

  Yes

  No

  N/A

• First Aid kit

  Yes

  No

  N/A

• Mobilephone/Telephone

  Yes

  No

  N/A

• Lifeline and retrieval system

  Yes

  No

  N/A

• Communication Arrangements

EMERGENCY EQUIPMENT

• Mobilephone

  Yes

  No

  N/A

• First Aid Kit

  Yes

  No

  N/A

• Torch

  Yes

  No

  N/A

• Communication Arrangements

  Yes

  No

  N/A

• Mobile phone

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Walkie talkie

  Yes

  No

  N/A

• I have reviewed the hazards and control measures documented in the relevant JSEA/SOP for this task. I believe that the work can be completed safely provided all the above-mentioned precautions and the relevant JSEA/SOP are complied with

• Permit Issuer

  Sign

• Permit User

  Sign

• Permit User

  Sign

• Safety Observer

  Yes

  No

  N/A

• Name and Signature

  Sign

• The permit has been suspended due to work not being completed. The following precautions have been completed in the work area

• Area access restricted

• Isolation retested

• Equipment Secured

• Signage in place

• Area Manager notified

• This Permit has been revalidated to allow suspended work to be recommenced. The following precautions have been completed

• Area Inspected

• Environmental conditions safe

• Pre-start checks completed

• Area Manager notified

• Permit Issuer

  Sign

• Permit User

  Sign

• I have inspected the work area and certify that all personnel, tools and equipment have been removed from the area, all guards and covers have been replaced, all LOTO devices have been removed and all barriers and notices removed. I confirm that the area is safe for normal operations to resumes.

• Permit Issuer

  Sign