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Working at Height Permit Form

The document is a Working at Height Permit to Work Form that collects essential information regarding work being performed at height, including general details, task description, height specifics, risk assessment, control measures, personnel involved, and authorization. It requires signatures from both the supervisor and the worker to confirm understanding and compliance with safety requirements. The form also includes a section for permit closure and comments upon completion of the work.

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nazir24s
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10 views3 pages

Working at Height Permit Form

The document is a Working at Height Permit to Work Form that collects essential information regarding work being performed at height, including general details, task description, height specifics, risk assessment, control measures, personnel involved, and authorization. It requires signatures from both the supervisor and the worker to confirm understanding and compliance with safety requirements. The form also includes a section for permit closure and comments upon completion of the work.

Uploaded by

nazir24s
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
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Working at Height Permit to Work Form

1. General Information
 Permit Number:
 Date Issued:
 Location of Work:
 Department:
 Person Requesting Permit:
 Contact Number:

2. Description of Work
Brief description of the task to be performed:

Estimated duration of the work:

Start Date/Time: End Date/Time:

3. Height Details
Height of work:

Means of access:

 [ ] Ladder
 [ ] Scaffold
 [ ] Mobile Elevated Work Platform (MEWP)
 [ ] Fall Arrest System
 [ ] Other (Specify):

4. Risk Assessment
Has a risk assessment been completed?

 [ ] Yes [ ] No

Key hazards identified (tick all that apply):

 [ ] Falling from height


 [ ] Falling objects
 [ ] Weather conditions
 [ ] Electrical hazards
 [ ] Fragile surfaces
 [ ] Other:

5. Control Measures Implemented


 [ ] Guardrails installed
 [ ] Safety harness and lanyard provided
 [ ] Fall arrest system in place and inspected
 [ ] Tools tethered
 [ ] Area cordoned off below
 [ ] Weather conditions assessed
 [ ] Trained personnel only

Other control measures:

6. Personnel Involved
Name Role Trained for Working at
Height? (Y/N)

7. Permit Authorization
Supervisor Name:

Signature:

Date/Time:

8. Permit Acceptance by Worker


I have read and understood the requirements of this permit and agree to comply with all
stated precautions and safety requirements.

Worker Name:

Signature:

Date/Time:
9. Permit Closure
Work completed on:

Permit closed by (Name & Signature):

Comments (if any):

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