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Height Work Permit

The document is a Work At Height Permit application for tasks performed above six feet, detailing necessary safety checks and compliance measures. It includes sections for work description, location, time, personnel involved, and a checklist for safety precautions such as risk analysis, equipment safety, and personal protective equipment. The permit requires signatures from the initiator, supervisor, and safety officer to confirm that all safety measures have been taken before work commences.

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Rina Praharaj
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15 views1 page

Height Work Permit

The document is a Work At Height Permit application for tasks performed above six feet, detailing necessary safety checks and compliance measures. It includes sections for work description, location, time, personnel involved, and a checklist for safety precautions such as risk analysis, equipment safety, and personal protective equipment. The permit requires signatures from the initiator, supervisor, and safety officer to confirm that all safety measures have been taken before work commences.

Uploaded by

Rina Praharaj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Doc No.

QR-EHS-08
Work At Height Permit(Above 6 Feet) Rev No. /dt: 01/20.07.2019

Permit Application By Initiator:-


Description of Work-
Location of Work- Time From- (Hrs)
Date- Time To- (Hrs)
Name of Supervisor Department-

Name Of Authorized Persons Carrying Out The Job(Trained in Use Of Required Procedures,Tools/Equipment,PPE etc)
1 2 3 4
S.No. SAFETY CHECKS FOR COMPLIANCE Yes/No NA
Risk Analysis of Adjoining Equipment/Area And Operations Considered For The
1 Job?

2 Safe Stand/Ladders Provided to Aproach Work At Height?

3 Ladders Tied and Supported Safety At Ends?


Is Safe Work Platform/Scaffold Of Construction Provided & Checked For Its
4 Safe Use?

5 Support Railling Provided Around Platform/Scaffolding?


Area Below Work Place Cordoned/Cleared Off And Sign Board Put Up For
6 Warning?
Ensure Full Body Safety Harness With Double Lanyard & Hook is Provided & its
7 Safe Use?
Is Provision For Tie Up Of Full Safety Harness To Rigid Structure Or Correct Life
8 Line?
9 Is Safety Net Stretch Under Work Place?If Required.
Area Below Work Place Cordoned/Cleared Off And Sign Board Put Up For
10 Warning?
11 Availibility Of Safe Access & Exit?

12 One Observer/Attendant is Designated And Is Present At Worksite


13 Is Fall Arrestor Provided?
Ensure Cooling Of Piping/Equipment/ On Which Work To Be Done,If They Are
14 Abnormally Hot?
15 Tick The Safety Appliances To Be Used
Safety Helmet Safety Belt Safety Shoes
Hand Gloves Nose Mask Safety Goggles Any Others
I Confirm To Have Checked & Taken Necessary Measures As Indicated And Ticked Above.
Name Of Initiator Person Name Of Job Supervisor
Name Sign- Name Sign-
Date- Time- Date- Time-
Name Of Area HOD/Area Supervisor Safety Officer/Security Incharge
Name Sign- Name Sign-
Date- Time- Date- Time-
Work Completed & Closure: I Confirm That Work Completed On ____________(Date,Time)

Name of Supervisor-
Signature

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