Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Working At Heights Permit
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Permit No:
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Work Location:
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Type of work being conducted:
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Permit Valid FROM:
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Date & Time:
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Permit Valid TO:
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Date & Time:
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All fields must be completed, indicate with either YES, No or N/A (Not applicable).
Permit numbers must be listed also.
Does this Permit combine with any other Permit or Permits?
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Isolation Permit
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Permit No:
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Confined Space Permit:
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Permit No:
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Hot Works Permit:
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Permit No:
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Excavation Permit
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Permit No:
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Permit to Work
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Permit No:
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Cause an Opening Permit
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Permit No:
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Other
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List Permit & No:
Answer all questions below with Y, N or N/A.
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All personal working on this Task are "Working at Heights" trained & Competent?
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A Current Risk Assessment has been completed for the work this permit is applicable to?
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The requirement for a Rescue Plan or an Emergency Response Plan has been assessed?
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All of the Working at Heights Equipment has been inspected and servicable?
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The Working at Heights Exclusion Zone been demarcated?
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The Task being conducted going to cause an opening (eg. Lifting grid mesh, removing handrail)?<br>If Yes, Hard Barricading must be erected by a qualified scaffolder before the opening is created.
What Mode/s, Equipment or Ladders are required for this Permit?
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Restraint Technique Mode
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Personal are restrained so they can not reach a position where a fall is possible.
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Personnel can maintain a secure footing at all times.
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An approved full body Fall arrest harness is being used
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Anchor Points meet the Australian Standards (15kN one person os 21kN for two persons)
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Limited Freefall Mode
(600mm fall or less before before a fall arrest system takes up) -
An approved full body Fall arrest harness is being used
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An Inertia Reel or shock absorbing device has been fitted to prevent a fall greater than 600mm
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Anchor Points meet the Australian Standards (15kN one person os 21kN for two persons)
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Restrained Fall Mode (Roof Work, Pole Work)
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A shock absorbing system is fitted
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An approved full body Fall arrest harness is being used
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Anchor Points meet the Australian Standards (15kN one person os 21kN for two persons)
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Ladders
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Personal are restrained so they can not reach a position where a fall is possible.
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The ladder is secure/stable to prevent movement
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Fall prevention controls are in place if the ladder is within 2 meters of hand rail, open edge or moving equipment
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Industrial Rope Access
(Authorised personal / Rope Access Technician) -
Minimum of 3 persons required<br>2 x IRA Technicians & 1 x Standby Person
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Area Manager has authorised the Risk Assessment
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Scoffolding
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The ground conditions are suitable for the task
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All Scaffolders are Qualified ?
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What Duty is the Scaffold required to be
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EWP/MEWP
Elevated Work Platform / Mobile EWP -
A pre-start inspection has been conducted and recorded
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The ground conditions are suitable for the task
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All overhead hazards in the work area have been identified and controled
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Fall arrest controls are in place for all personal in the "Basket"
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Operator and Standby person are qualified for EWP operations.
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Personal Cage
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An approved Critical Lift Permit been completed
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A pre-start inspection has been performed and recorded (Dogman)
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All overhead hazards in work area are identified and controled
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Personal operating the lifting equipment are competent and certified (crane operator)
Authority to Work at Heights
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Responsible Person.
I Accept the responsibility of this Permit as the person directly in charge of the work. -
Name & Sign:
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Date & Time:
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Standby Person.
I understand and accept the responsibilities of the standby person. -
Name & Sign:
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Date & Time:
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Authorising Person.
I have advised the person nominated above of the conditions of this permit and authorise Working at Heights to be carried out subjected to the conditions of the risk assessment. -
Name & Sign:
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Date & Time:
Rescue Plan (High risk activities require the development of an Emergency response plan)
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Emergency Radio Channel.
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Emergency Number/s.
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What will you do is something goes wrong?
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What rescue equipment are at the work location?
Nominated Standby Person I have read and understand the rescue plan and will be able to implement if if required.
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I have checked all of the personal are currently qualified to Work at Heights
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I have briefed all personal on the rescue plan
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I have briefed all personal on the communication plan
Standby Name, Sign onto the Permit
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Standby Name and Sign ON:
Person
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Name & Sign
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Date & Time
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Standby Name and Sign OFF:
Person
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Name & Sign.
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Date & Time.
Working at Heights Personal I have been trained, I have read and agree to the conditions of this Permit
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Working at Heights Personal Name and Sign ON:
Person
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Name & Sign
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Date & Time
Working at Heights Personal Name and Sign OFF:
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Name & Sign
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Date & Time
Permit Closure (To be completed by Responsible Person)
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All working at Heights PPE has been returned, inspected and accounted for?
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All work associated with this Permit has been completed. The work and adjacent areas have been inspected and have been left in a safe condition.
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List any Controls left in place:
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Name & Sign:
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Date & Time:
