• Document No.

  • Conducted on

  • Prepared by

  • Location

Roof Access

  • Centre/Location:

  • Date

  • Company Name:

  • Permit Receiver & Phone Number

  • Description of Work

  • Location of Work:

  • Permit Issuer Name:

  • Vicinity Centres Position:

Roof Access

  • Appropriate SWMS or other risk assessment documentation in place

  • Communication protocols included in SWMS or other risk assessment documentation

  • Appropriate keys obtained

  • Radio frequency radiation plan/manual reviewed and understood

  • Roof Safety Audit Report reviewed and understood

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

  • This permit is valid till: Expiry date & Time

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

  • Permit Receiver:

  • Permit Issuer:

Permit Close Out

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

  • Date & Time

  • Permit Receiver:

  • Permit Issuer:

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.