Permit to Work - Working at Height v2

• Project or Program Name

• Conducted on

  Date
• Full site details: Building name, floor, room and/or address
  Address

• Permit Reviewed and Issued by

• Contractor Details

• This Permit is only Valid when all sections are complete and should be read in conjunction with the risk assessments submitted for the work being conducted. If you are in doubt or don't understand, then please ask. Remember, all accidents, incidents, injuries and near misses are preventable. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE SAFETY, RISK & ASSURANCE TEAM.

• Is a completed Risk Assessment that meets the University requirements present and understood by workers?

  Yes

  No

  N/A

• What works will be undertaken?

• What is the estimated height of the works being undertaken?

• If the work exceeds 5 metres in height has WorkSafe been notified?

  Yes

  No

  N/A

• Is the WorkSafe notification or number available onsite for reference?

• Special Tools / Equipment to be Used (full name or type of equipment, such as Elevated Work Platform)

• Is any other work currently being undertaken that may interact or affect this permit, such as a Hot Works Permit or Working with Asbestos Permit?

  Yes

  No

  N/A

• Have the building occupants been consulted/advised of the work to ensure that there is no conflicting work?

  Yes

  No

  N/A

• Will there be any impact on pedestrian routes or emergency egress?

  Yes

  No

  N/A

• Is a Traffic Management Plan (TMP) required for this work or provided?

  Yes

  No

  N/A

• Has the most appropriate equipment been chosen for work at height e.g. scaffolding, mobile scaffolding, elevated platform, ladder

  Yes

  No

  N/A

• If work is being conducted within 4m of overhead power lines is effective isolation in place (e.g. power disconnection, sleeving, or close approach consent).

  Yes

  No

  N/A

• Are all workers completing working at height appropriately qualified or trained to undertake this work?

  Yes

  No

  N/A

• Have Warning Signs been erected warning of Working at Height Taking place?

  Yes

  No

  N/A

• Has the Drop Zone been fenced or barricaded?

  Yes

  No

  N/A

• If the nature of the works could affect smoke detectors, heat detectors, sprinklers, infrared sensors or fire curtains has the appropriate Fire Protection System isolation request been completed and approved before work commences?

  Yes

  No

  N/A

• Has the weather forecast been checked?

  Yes

  No

  N/A

• Is there a robust Emergency Response or Rescue Plan for getting an injured or unwell worker down from working at height?

  Yes

  No

  N/A

Review of chosen working at height equipment

• Roof Access

  Selected

• Is a safe means of access and egress to the roof provided?

  Yes

  No

  N/A

• Have Fragile Surfaces been Protected? (i.e. Poly Carbonate or Glass Skylights - Covered or Fenced off)

  Yes

  No

  N/A

• Is appropriate or effective Edge Protection in Place?

  Yes

  No

  N/A

• Are Fixed Lines or Engineered Anchor Points provided to secure workers using a Harness and Lanyard?

  Yes

  No

  N/A

• Have the Fixed Line or Engineered Anchor Points been Inspected and tagged as safe in the last 12 months?

  Yes

  No

  Unable to assess

• Is the roof free of ice / frost?

  Yes

  No

  Unable to assess

• Abseiling, Fall Restraint or Fall Arrest

  Selected

• Has the height safety equipment being used for this work been inspected in the last 6 months?

  Yes

  No

  N/A

• Is the Fall Arrest Lanyard the correct length? (i.e. 3 m shorter than the height of the structure)

  Yes

  No

  N/A

• Elevated Work Platform or EWP (Incl. Scissor Lift / Boom Lift but not limited to)

  Selected

• Do you hold a current EWP Licence or Qualification?

  Yes

  No

  N/A

• Has the EWP got a valid six monthly Inspection Certificate Plate displayed?

  Yes

  No

  N/A

• Have you checked the work area including access ways for fragile or uneven surfaces i.e. drain lids / manhole covers etc?

  Yes

  No

  N/A

• Have you checked the instruction manual or sought advice from the hireage company on safe wind speeds to operate this EWP?

  Yes

  No

  N/A

• Have you got a Harness and Fixed Lanyard for working in the bucket?

  Yes

  No

  N/A

• Have you checked for overhead hazards or obstructions to avoid injuries i.e. cables, pipes, hatches, vents?

  Yes

  No

  N/A

• Is there a Standby Person on the ground trained to use the lowering controls in the event of a breakdown?

  Yes

  No

  N/A

• Scaffolding (Fixed)

  Selected

• Has the scaffold been designed / erected and inspected by a competent person - and load rated for the works to be undertaken?

  Yes

  No

  N/A

• Is the scaffold tied or braced to the structure using approved methods?

  Yes

  No

  N/A

• Has the scaffold been fitted with a Scaff Tag Inspection System?

  Yes

  No

  N/A

• Has the Scaff Tag been completed in the last 7 days?

  Yes

  No

  N/A

• Is the Scaffolding protected from Vehicle Impacts at the base?

  Yes

  No

  N/A

• Are scrim or catch nets required on the scaffolding to stop items falling?

  Yes

  No

  N/A

• Are access ladders secured correctly / protected by self closing gates to prevent unauthorised access?

  Yes

  No

  N/A

• Is the scaffold protected at night, to prevent trespassers / unauthorised access?

  Yes

  No

  N/A

• Is scaffolding installed to standard (e.g. soleboards 500mm x 200mm x 38mm thick, base boards, platforms, toe boards, stabilising legs, stand offs, gates, ladder attachments, edge protection installed effectively)

  Yes

  No

  N/A

• Mobile Scaffold

  Selected

• Has the scaffold been erected and inspected by a competent person - and load rated for the works to be undertaken?

  Yes

  No

  N/A

• Is the work platform set up correctly (top rail 1100 mm high, mid rail 600 mm & toe boards 150 mm high)?

  Yes

  No

  N/A

• Have the wheels been leveled and locked?

  Yes

  No

  N/A

• Ladders Section

  Selected

• Is the ladder suitable for the Environment - i.e. Fibreglass Non- conductive ladder for electrical works?

  Yes

  No

  N/A

• Is the ladder / stepladder industrial rated and meets the trade or industrial standard with a rating of either 120 kg or 150 kg and complies with the AS/NZS 1892 standard?

  Yes

  No

  N/A

• Is the ladder / stepladder in good condition and with rating label in place?

  Yes

  No

  N/A

• Is the ladder / stepladder been used for works of Short Duration (Max 30 mins in the same location) and Light Works (Max 25 kg Tools / Equipment)

  Yes

  No

  N/A

• Is the ladder set up at 1:4 ratio (1m horizontal to 4m vertical)

  Yes

  No

  N/A

• Can users maintain 3 points of contact at all times

  Yes

  No

  N/A

• Is the ladder secured at top and base to prevent slipping sideways/out

  Yes

  No

  N/A

• Do all ladders have more than 3 steps

  Yes

  No

  N/A

• Power Supply Section

  Selected

• If power isolated is a lock out device in place with tag?

  Yes

  No

  N/A

• Are appropriate RCDs or safety devices in place?

  Yes

  No

  N/A

• Have power source or extension leads been tagged?

  Yes

  No

  N/A

• Are tags valid and leads in good working order?

  Yes

  No

  N/A

• Are leads used in a safe manner?

  Yes

  No

  N/A

• Tools & Machinery Section

  Selected

• Are all tools or materials secured while working at height?

  Yes

  No

  N/A

• Are the right tools or machinery being used for the job?

  Yes

  No

  N/A

• Are power tool tags valid?

  Yes

  No

  N/A

• Are all dangerous parts guarded?

  Yes

  No

  N/A

• Do all tools and machinery appear to be in good working order?

  Yes

  No

  N/A

Supervisor or Manager in charge of these works

• Company

• Contact Name

• Signature

  Sign

Permit Issuer

• Name

• Signature

  Sign

Permit start and expiry dates/times

• Issued

  Date

• Expires

  Date

General comments

• Add media

  Media