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PTW-Work at Heights

The document is a permit for work at heights. It outlines requirements for equipment, isolation of services, control measures, and environmental factors. It requires authorization signatures from those issuing and receiving the permit.

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amran hakimi
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489 views2 pages

PTW-Work at Heights

The document is a permit for work at heights. It outlines requirements for equipment, isolation of services, control measures, and environmental factors. It requires authorization signatures from those issuing and receiving the permit.

Uploaded by

amran hakimi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Permit to Work Ref.

No:
(Work at Heights) Date:
Page 1 of 2

No:
Authorised By:
Issue Date:
Last Reviewed:
Next Review Date:

Permit Number: Date:     


Site:
Location:
Contractor/Employee: Phone:      
This permit is valid from:       am/pm On:      
This permit is valid until:       am/pm On:      
Description of works:
A Safe Work Method Statement (SWMS), Job Safety Analysis (JSA) and/or Safe Work Procedure (SWP) has been provided
and is attached to this ‘work permit’ Yes No
Note: The following section of this permit must be completed and signed by the authorised person(s) before work is to
proceed and only work listed above may be completed.
The following equipment will be used during the works (all equipment to be used is in good working order and is fit for
use):
Elevated work platform (i.e., scissor Roof and/or ladder anchor
Ropes and harness
lift) points
Step ladder Extension ladder Edge protection
Mobile scaffold Appropriate footwear Safety net
Other (please specify):
The following services have been isolated for the duration of the works:
Smoke / thermal detectors Pipes, tanks and valves Electrical Outlets / appliances
Other (please specify):
The following control measures have been implemented for the duration of the works:
Barricades Signage Spotter
Other (please specify):
The following environmental factors have been assessed and are suitable for the works:
Weather/wind Stored material/vegetation
Other (please specify):

HSE Documents-C/PTW/P001 Rev00


Permit to Work Ref. No:
(Work at Heights) Date:
Page 2 of 2

This permit should be prominently displayed at the worksite

Authorisation

Permit Issued To: (Print name) (Signature) (Date)

Permit Issued By: (Print name) (Signature) (Date)

Cancellation/completion of permit

Permit cancelled/returned by: (Print name) (Signature)

Cancelled/returned at: am/pm On:

Reason for cancellation:

Final Sign Off


The work site has been inspected by me at the cancellation/completion of the work at heights and declared safe for normal operations to
resume.

(Print name) (Signature) (Date)

HSE Documents-C/PTW/P001 Rev00

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