Safe Work at Heights Permit - V 01 (Draft)

The purpose of this permit is to ensure that all personnel who are required to Work at Heights are authorised to do so, and that risk assessments have been completed with hazards identified and control measures are in place. This permit is valid only until the completion of this activity or reaching the expiry date.

• Project

• Date

  Date

• Training Area

• Work Location

• Safe Work at Heights Permit Number

Validity

• Start Date/Time

  Date

• Finish Date/Time

  Date

• Responsible Supervisor

  Select

1. General- This section is to be compiled and completed upon arrival at work location prior to any work at heights activities. This permit is to be constantly monitored for the duration of the activities.

• Description of tasks to be carried out whilst working at height

• What is the type of structure?

  Free Standing Tower

  Lattice Guyed Mast

  Guyed Mast

  Roof

  Other

• Description

• Method of Access

  Select Fixed Ladder with LADSAF Portable Ladder Elevated Work Platform (boom lift) Elevated Work Platform (scissor lift) Other

  • Fixed Ladder with LADSAF
  • Portable Ladder
  • Elevated Work Platform (boom lift)
  • Elevated Work Platform (scissor lift)
  • Other

• Provide Description

• Is Ladder serviceable and fit for purpose?

  Yes

  No

  N/A

• Is Ladder secured both Top & Bottom?

  Yes

  No

  N/A

• Operators Name

  Select

• Operator's Name

  Select

• Does the SWMS identify the requirements for Working at heights and identified all controls to be in place?

  Yes

  No

  N/A

• Describe any extra controls to be put in place.

• Have you informed the Responsible Supervisor?

  Yes

  No

  N/A

• SWMS Number

• Are all personnel 'Fit for Work'?

  Yes

  No

  N/A

• Ensure PPE required for the task serviceable and fit for purpose?

• Ensure all personnel required to work at height trained and competent?

• Is the ground conditions suitable for the range of activities to be conducted?

  Yes

  No

  N/A

• STOP work and inform Responsible Supervisor for direction

• Is the weather conditions suitable for the range of activities to be conducted?

  Yes

  No

  N/A

• Stop work and inform Responsible Supervisor for direction

• Ensure all personnel to be involved with activities aware of their individual responsibilities?

• Ensure that controls in place to prevent and manage dropped/falling objects? (lanyards, tethers etc.)

• If there is a requirement for personnel to be working below, are they aware of the activities being conducted and wearing the appropriate PPE? (Hard hats etc.)

  Yes

  No

  N/A

• Is there a competent rescuer on site?

• Ensure the rescue kit serviceable and fit for purpose?

• Ensure that there is a serviceable and complete remote first aid kit onsite?

I certify that I do not suffer from any conditions such as Vertigo, Epilepsy etc. that affect my ability to work at heights. I acknowledge that I am bound by the controls identified in the SWMS and this permit to safely conduct all tasks required whilst working at heights.

• Name

  Select

• Signature

  Sign
As an assigned rescuer, I am fully conversant with the requirements of this permit and accept the responsibility to conduct a rescue (if required)

• Name

  Select

• Signature

  Sign

As the Responsible Supervisor, I accept all responsibility to ensure that all controls identified in the SWMS and this permit are in place prior to the commencement of work, and to monitor throughout. I also accept the responsibility to inform the site supervisor of any changes or incidents that may arise for the duration of this permit.

• Name

  Select

• Signature

  Sign