Working At Height Permit To Work

• Permit No.

• Contracting Company

• Responsible Person

• Mobile phone number

• Additional Personal

• Location
  Address

• Conducted on

  Date

• Prepared by

• Activity Risk Level

  Low Risk

  Medium Risk

  High Risk

• Additional comments

General details

• Job Details

• Permit start

  Date

• Permit Estimated End

  Date

• PPE Requirements:

• Please state what PPE is required

  Select Safety boots Hard hats Safety Gloves Hi- Vis Clothing Hearing Protection Harness Respirator Eye Protection Life jackets

  • Safety boots
  • Hard hats
  • Safety Gloves
  • Hi- Vis Clothing
  • Hearing Protection
  • Harness
  • Respirator
  • Eye Protection
  • Life jackets

• Is there a risk assessment and method statement/SSOW available for the works

  Yes

  No

• State Reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Are the works being undertaken by competent personal

  Yes

  No

• Are these documents available

  Yes

  No

• State Reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Are the appropriate insurance documents available?

  Yes

  No

• State reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Will this work encroach upon any other work, for which a permit to work will be /has been issued?

  Yes

  No

• Has consultation and precautions taken place

  Yes

  No

• State reason why

• Do all attendees have a valid DFDS Immingham induction?

  Yes

  No

• state reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

Hazards and Precautions to be taken

• Are the weather conditions acceptable?

  Yes

  No

  N/A

• Is the area clear and free from hazards?

  Yes

  No

  N/A

• What actions are to take place

• Can working at height be avoided?

  Yes

  No

  N/A

• How can this be avoided?

• Is there a danger of falling?

  Yes

  No

  N/A

• Is there a risk of falling objects?

  Yes

  No

  N/A

• Is there a danger to others not working?

  Yes

  No

  N/A

• Have tools & equipment been inspected?

  Yes

  No

  N/A

• Is the work at height a short duration?

  Yes

  No

• What form of equipment is to be used whilst working at height

  Select Use of Mewp/Sissor lift Ladders/ step ladders Scaffolding Other, Please state

  • Use of Mewp/Sissor lift
  • Ladders/ step ladders
  • Scaffolding
  • Other, Please state

• Please state

• Is a safety harness required

  Yes

  No

• Has this been inspected?

  Yes

  No

• State reason

  Yes

  No

• Are there any other factors that could effect the safety of the workers

• Additional Comments

Authorization and Acceptance

• I confirm that I have accepted responsibility for the works to be carried out, and will ensure all health and safety and hygiene instructions are complied with. Competent authorised persons will carry out the works in accordance with the risk assessment & method statement

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• I am competent to authorise this permit, subject to the conditions indicated the works may proceed

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date

Hand Back and Cancellation

• I certify that

• undefined

  Select The work has been completed Equipment has been removed Plant and machinery has safely been returned to service Disable fire protection zones have been reinstated

  • The work has been completed
  • Equipment has been removed
  • Plant and machinery has safely been returned to service
  • Disable fire protection zones have been reinstated

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date