Working at heights permit form template

Permit No:

Date of Issue:

Expiry Date:

Work Location:

Description of Work (including tasks to be performed):

1. Personnel Involved

• Name of Supervisor/Manager:

• Name(s) of Worker(s):

2. Hazard Identification and Risk Assessment

• Potential Hazards Identified:

  • Falling objects
  • Falls from height
  • Slips, trips, and falls
  • Inadequate access/egress
  • Weather conditions (wind, rain, etc.)
  • Electrical hazards
  • Other (specify):

• Control Measures in Place:
  (e.g., guardrails, scaffolding, fall arrest systems, etc.)

  • Guardrails/barriers
  • Personal fall arrest systems (harnesses, lanyards)
  • Safe access/egress
  • Inspection of ladders/scaffolding
  • Weather monitoring
  • Other (specify):

• Has a Risk Assessment been conducted and reviewed for the work at height?
  [ ] Yes
  [ ] No

3. Equipment and PPE Required

• Required