Working at Height Permit

• Site

• Date

  Date

• Prepared by

• Location

• Job Details

• Specific tools/equipment used

• Is there any other work being undertaken that may affect this permit?

  Yes

  No

  N/A

• Are you qualified/trained to undertake this work?

  Yes

  No

  N/A

• Are appropriate signs to be erected?

  Yes

  No

  N/A

• Is area to be barricaded?

  Yes

  No

  N/A

• Are crawl boards with handrails and access ladders/roof ladders to be used?

  Yes

  No

  N/A

• Is scaffolding required?

  Yes

  No

  N/A

• If yes, is scaffolding in place and inspected?

  Yes

  No

  N/A

• Is a harness required?

  Yes

  No

  N/A

• Has the harness(es) been inspected?

  Yes

  No

  N/A

• Are weather conditions acceptable?

  Yes

  No

  N/A

• Are there any ducts or outlets on roof?

  Yes

  No

  N/A

• If yes, any hazards from fumes, etc.?

  Yes

  No

  N/A

• Is there any risk from falling objects?

  Yes

  No

  N/A

• Are there any existing overhead services crossing and/or adjacent to proposed height working?

  Yes

  No

  N/A

• Is edge protection/toeboards required? (roof or scaffold)

  Yes

  No

  N/A

• Are guard rails required?

  Yes

  No

  N/A

• Is a licence required for scaffolding?

  Yes

  No

  N/A

• Is Personal Protective Equipment required?

  Yes

  No

  N/A

• Other precautions required

• Other safety equipment required

AUTHORISATION AND ACCEPTANCE

• I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the work as defined above and the permit information has been explained to all workers involved. I accept responsibility for this work.

  Yes

  No

  N/A

• NAME

• SIGNATURE

  Sign

• DATE & TIME

  Date

• AUTHORISING PERSON

• SIGNATURE

  Sign

• I confirm that the work has been completed, checked by myself and the area left in a safe and tidy condition.

  Yes

  No

  N/A

• PERSON IN CHARGE

• I have inspected the completed/partially completed work and hereby complete/cancel this permit.

• DATE & TIME

  Date

• AUTHORISING SIGNATURE

  Sign