MASTERS MASTERS/PMF/34
Permit - Work at Height
PROJECT NAME: Package Contractor:
Activity: Location: Package No.:
Start Date and time Estimated Finish Date and time:
Be sure to ask the following and review the job risks while Tick where any of the following are required:
working at height before starting the work in nights at heights, Personal Special equipment &
duly fill the format and get it approved by site in charge. protective Permits
equipment:
Have you walked the work area? Yes / No Fall Confined Space
Protection
Are there any barricades needed - around, above Yes / No Hearing Excavation
or below? protectio
n
Is work around live electrical equipment or Yes / No Footwear Energized Electrical
operating equipment? Work
Is all the emergency equipment identified - e.g. fire Yes / No Eye / face High Voltage
extinguisher, phones, chemical shower etc?
Are evacuation routes known and clear? Yes / No Respirato Hot Work
r
Have all the necessary people been contacted? Yes / No Dust
Has the safe work method been prepared? Yes / No Hand /
Arm
Is the area congested with other trades? Yes / No Knee
Pads
Are shop drawings at hand? Yes / No Full body
Are enough people assigned to the job to carry out Yes / No Rescue
the safety measures? equipmen
t
Does the task require special permits to work or Yes / No
procedures? Name and Signature of the Site
Engineer (Sub-Contractor):
Does the task require special training? What? Yes / No
Is the arrangement for task lighting sufficient and Yes / No
safe? Date:
Will weather conditions affect the safe conduct of Yes / No
the work?
Is work at height hazards identified for all stages of Yes / No
the task?
Are there adequate tools & materials for the job? Yes / No
Are there any wastes generated? Are any fluids Yes / No Comments:
flushed or spilt Do they require special disposal or
reuse?
Have all electrical equipment & cables been Yes / No Name and Signature of MMC Rep. :
inspected prior to use?
Have all workers been trained in the proper use of Yes / No
safety equipments
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MASTERS MASTERS/PMF/34
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