WORK AT HEIGHTPERMIT
1. Project Information: (To be filled by initiator/originator)
Work Location: Permit No.:
Work Description:
Permit Requested by
2. Permit Issuance Details: (To be filled by initiator/originator)
Description of Work:
Detail of
Surroundings:
Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
Work at height on fragile surfaces
Work at height without guardrails
Type:
Height work within the Confined Space
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated?
Area barricaded &proper signage are posted?
Qualified and briefed workers?
PPE of workers available &inspected as per MS/RA?
Tools/Equipment inspected?
Safe means of access/ Egress?
Lifeline available and inspected?
Fragile surface covered / work surface protected?
Dimensions of platform and restrain lanyard match safety requirement?
Harness with double lanyard provided and its use briefed to workforce?
Harness anchorage point checked?
Load bearing capacity of anchoring point checked?
Load bearing capacity of fragile service checked?
Emergency response procedure and rescue plan are developed & communicated?
Others ( Specify)
4. Acknowledgement by Initiator and Evaluator:
Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I
consider them competent to do it safely.
Page 1 of 2 Form # HSEQ-WHP(Rev 2 - Mar 23)
WORK AT HEIGHTPERMIT
Initiator/Originator
Designation:
Name:
Signature: Date /Time:
Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
6. Completion/Cancelation of Permit:
Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature : Time:
CHECK ALL POTENTIAL HAZARDS/ RISK IMPACTS AS APPLICABLE:
Temperature extremes Mechanical equipment
Severe/ adverse weather Noise Moving equipment (or parts)
Overhead power lines Electrocution Engulfment
Overhead activities Slip, trip and fall Radiation
Falling objects Poor visibility Entry and exit limitations
Other Anticipated Hazards
(describe below)
Page 2 of 2 Form # HSEQ-WHP(Rev 2 - Mar 23)
