• The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.

  • Document No.

  • Maximo Work Order Number

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


The version control will be maintained by the SHEQ team and is controlled via the Safety Equipment Inspections Document 2073838157-15.

General Information This permit must be completed for:  Any work requiring personnel to wear harnesses as the primary control (fall restraint / fall arrest)  Using a workbox – refer to Crane workbox permit TP-CSC-CL-112  Ladders more than 4 metres in length (except when used by specialists, e.g. workers on electrical poles)  Working within two meters of roof edge without edge protection A Work at Height permit is not required for:  Work performed on a solid construction with edge protection  Routine work performed from completed scaffolding, EWPs (even where a harness is required) or portable work platforms  Routine plant maintenance conducted wearing a safety harness  Access and egress using ladders or hoists

  • State which Fall Protection Equipment is Required: Restraint or Arrest

  • Select date

STEP 2: MANDATORY REQUIREMENTS Answer ‘Yes’ , ‘No’ or ‘N/A’ for each question If you answer “No” to any of these questions you can not work at height.

  • Are personnel operating EWPs and hoists certified to do so?

  • Are all single-person fall-arrest anchor points capable of withstanding 15kN?

  • Have controls been put in place to ensure no person at height will be working in isolation?

  • Do personnel working at height have chin straps fitted to their helmets?

  • Does the work method protect workers on lower levels?

  • Have personnel working or operating equipment at height received adequate information, instruction and training?

  • Do all fall-arrest systems use a full-body harness with a shock-absorbing lanyard or inertia device?

  • Is all fall protection equipment tagged with current inspection dates?

  • Do all elevated work platforms, lift boxes, work boxes and sully boxes comply with the relevant standards?

  • Is a dual lanyard system in use if the work method requires a worker to detach and reattach at height?

  • Is an emergency response plan in place to recover a person who has been injured, suspended or trapped at height?

  • Has an exclusion zone been established below the work area?

STEP 3: WORK ASSESSMENT–HIGH-RISK WORK SITUATIONS Answer ‘Yes’ , ‘No’ or ‘N/A’ for each question If you answer “Yes” to any of these questions you must perform a Risk Assessment.

  • Will there be any interaction between the activity and its environment (general public or surrounding operations)?

  • Does the work area interface with mobile plant or passing traffic?

  • Will building materials or large tools/equipment need to be manually carried to the work area?

  • Will workers be performing tasks in adverse weather conditions?

  • Does the work area contain energised services (e.g. electricity, steam, gas, chemicals)?

  • Will there be work at height involving demolition or dismantling of a structure?

  • Is the work in, over or adjacent to a pit or shaft?

  • Does the work area include potentially unstable surfaces (e.g. ground conditions)?

  • Will work be performed over or on water?

  • Will plant or equipment be accessed at height under operational conditions (e.g. mast of piling rig or crane)?

  • Will plant or equipment be inspected or maintained at height outside of an encapsulated platform?

  • Will work take place on fragile surfaces (e.g. fibreglass roofs)?


  • Are all required controls in place? If No You Can Not Work At Height.<br>If Yes Go To Step 5


  • Add signature

  • Add signature

  • Add signature

  • Add signature


  • Add signature

  • Person in Control of the Work (e.g. person performing work) I accept this permit, agree to be bound by the conditions above and the associated procedures, and accept responsibility as the person directly in charge of the work. I have communicated the attached risk assessments/JSEA, post-fall recovery plan and have implemented the risk controls.

  • Add signature

  • Person Giving Authorisation (DTL, Leading Hand) I authorise the work at height subject to the conditions & precautions of the permit as indicated on the risk assessment.

  • Add signature


  • All work associated with this permit has been: Completed Cancelled or Suspended

  • The work area & adjacent areas have been inspected after completion of the work & all hazards have been made safe:

  • Person in Control of the Work (e.g. Supervisor, senior person performing work)


  • Work Description

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.