Vicinity - Work at Height, Roof Access and BMU Permit HS-FR-10-02

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Work at Height, Roof Access and BMU Permit

• Centre/Location:

• Date

  Date

• Company Name:

• Permit Receiver & Phone Number

• Description of Work

• Location of Work:

• Permit Issuer Name:

• Vicinity Centres Position:

Work At Height

• Appropriate SWMS or risk assessment in place

  Yes

• Ladder use is appropriately addressed by SMWS or other risk assessment documentation

  Yes

  N/A

• Demonstrated appropriate competency for use of fall restraint/arrest equipment

  Yes

  N/A

• Fall restraint/arrest equipment inspected prior to use e.g. equipment tagged or log books available

  Yes

  N/A

• Anchor points have been inspected/tested and tagged (current)

  Yes

  N/A

• Rescue plan in place where fall arrest equipment is in use, including spotter

  Yes

  N/A

• High risk license in place for boom type EWP that extends > 11m

  Yes

  N/A

• Controls in place for potential falling objects e.g. tools tethered, barricading, spotter, catch platform, signage

  Yes

  N/A

• Barricades/signs in place to control access to mobile plant e.g. EWPs

  Yes

  N/A

• Spotter in place for use of EWP

  Yes

  N/A

• Scaffolds > 4m erected and dismantled by a licensed person

  Yes

  N/A

• Voids, skylights, penetrations adequately protected and signposted

  Yes

  N/A

Roof Access

• Appropriate SWMS or other risk assessment documentation in place

  Yes

• Communication protocols included in SWMS or other risk assessment documentation

  Yes

  N/A

• Appropriate keys obtained

  Yes

  N/A

• Radio frequency radiation plan/manual reviewed and understood

  Yes

  N/A

• Roof Safety Audit Report reviewed and understood

  Yes

  No

  N/A

Additional Permits Required

• Hot Work

• Excavations and Penetrations

• Critical Lift

• Fire System Impairment

• Confined Space Entry

Permit Approval

• Copy of SWMS or risk assessment attached?

• This permit is valid from: Start date & Time

  Date

• This permit is valid till: Expiry date & Time

  Date

• I understand the permit requirements and the controls specified will be implemented and monitored for effectiveness throughout the works:

• Permit Receiver:

  Sign

• Permit Issuer:

  Sign

Permit Close Out

• I have checked the worksite and confirm that all persons and tools are accounted for and that the site has been made safe:

• Date & Time

  Date

• Permit Receiver:

  Sign

• Permit Issuer:

  Sign