WORKING AT HEIGHTS PERMIT

TEMPLATE

Project Details

Project

Date

PERMIT No.

The purpose of this permit is to ensure that personnel who have to wear fall prevention equipment are authorised to do so, and that
risk assessments have been completed with hazards identified and control measures in place.

NOTE: This permit is valid only until the completion of activity stated below or on reaching the expiry date/time.

Does this permit combine with any other permits?

PERMIT Y N NUMBER PERMIT Y N NUMBER

Isolation Excavation

Confined Space Hot Work

Workbox Other? Provide details

Work location:

Purpose/Type of Work:

Start Date: Time: Finish Date: Time:

Responsible Supervisor:

When using the following controls / equipment, the following has been considered and applied where appropriate. Indicate with
either Yes, No or N/A.

GENERAL

SWMS have been developed for the task and signed by all work parties Yes No N/A

Are the personnel required to work at height trained and competent? Yes No N/A

The prestart inspection of the equipment has been completed and recorded? Yes No N/A

The ground conditions are suitable for the range of activities? Yes No N/A

There are no overhead or underground hazards that may affect safe operation? Yes No N/A

Controls such as lanyards, screens and barriers are in place to prevent and manage dropped/falling Yes No N/A
objects

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 Adequate exclusion zones such as physical barriers, barricading and/or lockouts to prevent entry Yes No N/A
by persons are installed directly beneath and immediately adjacent to areas where work is
occurring above.

Is an emergency rescue plan in place and understood? Yes No N/A

EWP/MAN CAGE

If using workbox/crane cage a workbox permit must be issued and approved Yes No N/A

A lift analysis has been completed for workbox operations? Yes No N/A

Is the stability and bearing pressure been verified by a competent engineer for the loads imposed Yes No N/A
by the EWP?

Is the maximum slope known and understood? Yes No N/A

The equipment is to be operated by a trained and competent person? Yes No N/A

The prestart inspection of the equipment has been done and recorded? Yes No N/A

The EWP can support the required number of personnel, tools, equipment and material? Yes No N/A

There are no overhead hazards that may affect safe operation? Yes No N/A

Baskets fitted with cage must have anti crush guarding in place Yes No N/A

Fall and edge protection

Any temporary anchor points and static lines are on the Temporary works control register, Yes No N/A
approved by the temporary works coordinator and inspected

Restraint equipment is rated for 15kN? Yes No N/A

The restraint anchor point is rated for 15kN loading? Yes No N/A

The harness to be used is suitable for the work being undertaken? Yes No N/A

Is the harness D shackle to be used rated for fall arrest? Yes No N/A

Rope Access System?

A minimum of three, including trained and competent Supervisor and two trained and competent Yes No N/A
personnel

A dual rope system is to be used for all rope system work? Yes No N/A

Ropes independent anchor points are rated for 15kN for each rope? Yes No N/A

Ladders

The ladder is suitable and in good working order? Yes No N/A

Works are not being conducted within 2m of handrail, open edge or moving equipment? Yes No N/A

Work being conducted within 2m of handrail, open edge or moving equipment has fall prevention Yes No N/A
controls in place?

AUTHORITY TO WORK

Responsible Supervisor. I accept this Permit and agree to be bound by the conditions above and the associated procedures and
accept the responsibility as the person directly in charge of the work.

Full Name Signature Date

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 Standby Person. I understand and accept the responsibilities of the standby person

Full Name Signature Date

Authorising Person.

I authorise the safe working with heights to the conditions and precautions of the risk assessment and as indicated on this permit

Full Name Signature Date

Work crew:

The primary sign off for the work crew is the relevant SWMS. In addition, the work crew may sign off on this permit where
required by project procedures and/or risk assessment

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

Full name Signature Date

© Laing O’Rourke Rev. 01 27/01/2021 https://nextgearsms.com/ WORKING AT HEIGHTS PERMIT – TEMPLATE