Title Page
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Prepared by
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Date Prepared
Working at Heights Permit
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PERMIT STARTS
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PERMIT ENDS
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PERMIT ISSUED BY: (Manager or Supervisor)
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Contact No:
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Permit issued Date & Time
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PERMIT ISSUED TO:
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Contact No:
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LOCATION OF WORKS:
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DESCRIPTION OF WORK TO BE CARRIED OUT Note: Only the work listed below may be carried out under this permit:
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List Names and Contact Numbers of all people working on this permit
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REVIEW OF WORK PROCEDURES
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A SWC, WPF or equivalent has been developed and has assessed the Working at Heights risk (Attach Copy)
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A Rescue plan has been developed identifying recovery procedure and equipment where fall arrest is used as a primary control. (Attach Copy)
- Yes
- No
- N/A
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When using a boom type EWP, a competent spotter is required
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All personnel have completed 105L068 Falls in the Workplace Training?
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All fall protection equipment has been inspected prior to use?
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Planned work has been communicated to relevant persons?
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Authorised Safety Observer
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Working at Heights Permit
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Not controlled when printed 116R027
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SPECIAL INSTRUCTIONS OR CONTROL MEASURES
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RISK ASSESSMENT
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Safe Work Checklist (SWC) or Work Planning Form (WPF) completed
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Additional Equipment Controls required
(The following ticked items where required and have been checked to ensure serviceable condition) -
Helmet
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Drop zones established
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Safety Boots
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Gloves
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Safety Glasses
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Ladders
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Communications
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Scaffolding
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EWP pre start completed
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Lanyards
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Attachment points
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Harness
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The following ticked items have been assessed in the WPF or SWC if applicable
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Weather
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Traffic
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Overhead Power Lines
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Barricades
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Signage
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WORK COMPLETED OR SUSPENDED
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Date/Time Work Completed or Suspended
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All personnel have been advised and withdrawn from the work area
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All tools and equipment have been removed from work area
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Work area is fit for use
