Title Page

  • Client

  • Report

  • Building Name and Address

  • Inform Number

  • AroFlo Job Number

  • Inspection Date

  • Employee(s) Completing Inspection

  • Email(s) of Employees Completing Inspection

Permit To Work

Working at Height Permission

  • Rooftype

  • Designed safe access/aggress point

  • Specific work at height activities

Job Site Condition

  • Clear of adjacent operating equipment

  • Safe access & aggress available

  • Full edge protection (guard rails)

  • Clear of overhead lines/services

  • Stable ground conditions

  • Weather conditions OK

Work At Heights Controls

  • Scaffolding

  • Work on Tanks

  • Ladders

  • Fall Arrest System

  • Work on Roofs

  • Overhead Work

Spotter

  • Communication Method

  • Please provide all relevant information.

  • Spotter Name 1

  • Spotter Name 2 (if required)

Retrieval Plan Requirements

  • Please make sure that you have fully identified the following requirements:
    Identify how to raise the alarm
    Identify all escape routes
    Provision of first aid
    Retrieval of suspended persons

Additional Precautions and Controls

  • Please list any Precautions and Controls

Permit Authorisation

  • Permit Start Date and Time

  • Permit End Date and Time

Sign Off

  • I understand the precautions and controls which must be taken to perform the specified work safety. I will communicate these requirements to all members of my crew and ensure ongoing compliance with the OHS legislation. I will finalise or update the permit when the work is complete or ceases for the day.

  • I have read and acknowledge the Working at Height Policy and Procedure

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.