Roof Access HS-FR-10-07

• Document No.

• Conducted on

  Date

• Prepared by

• Location
  Address

Roof Access

• Centre/Location:

• Date

  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

  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?

  Yes

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

• Date & Time

  Date

• Permit Receiver:

  Sign

• Permit Issuer:

  Sign