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):

  ---

  ---

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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 Equipment for Work at Heights:
  (e.g., ladders, scaffolding, elevated platforms)

  • Ladders (type and condition)
  • Scaffolding (certified)
  • Aerial lift/platform (certified)
  • Other (specify):

    ---

• Personal Protective Equipment (PPE):

  • Hard hats
  • High-visibility clothing
  • Harnesses and lanyards
  • Fall arrest systems
  • Safety footwear
  • Gloves
  • Other (specify):

    ---

4. Pre-Work Inspection and Checks

• Has all equipment been inspected and is it in good working order?
  [ ] Yes
  [ ] No

• Has the site been assessed for structural stability?
  [ ] Yes
  [ ] No

• Have weather conditions been evaluated to ensure safe working conditions?
  [ ] Yes
  [ ] No

• Is emergency rescue equipment in place and accessible?
  [ ] Yes
  [ ] No

• Has the worker(s) received appropriate training for working at heights?
  [ ] Yes
  [ ] No

5. Work Procedure and Monitoring

• Work Procedures:
  (e.g., steps involved in working at height, safety measures in place, access methods)

  • ---

  • ---

  • ---

• Monitoring and Supervision:
  (Who will monitor the work and ensure compliance with safety measures?)

  • Supervisor Name:

    ---

  • Monitoring Frequency:

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6. Emergency Procedures

• Emergency Contact Number(s):

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• First Aid and Medical Support on Site:
  [ ] Yes
  [ ] No

• Rescue Plan in Place for Fall Emergencies:
  [ ] Yes
  [ ] No

• Rescue Personnel Available:
  [ ] Yes
  [ ] No

7. Authorization

• Permit Issued By:
  (Name and signature of the person authorizing the work)

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• Work to Start Date:

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• Permit Expiry Date:

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• Worker(s) Acknowledgment:
  (Name and signature of worker(s) accepting the permit and conditions)

  ---

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• Supervisor/Manager Acknowledgment:
  (Name and signature of supervisor/manager overseeing the work)

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8. Post-Work Inspection and Close-Out

• Has the work been completed according to safety procedures?
  [ ] Yes
  [ ] No

• Has the site been cleaned and made safe post-work?
  [ ] Yes
  [ ] No

• Permit Closure Date:

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• Permit Closed By:
  (Name and signature)

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