Height Work Permit

Project Name: Date :

Contractor’s Name: Trade:
Supervisor’s Name: 2nd:
Names of Workers Location: -
seeking access: Job briefing to all crew members? :-
Scope of Work to be Permit valid from: _______am/pm to_______ am/pm.
performed at height:
DESCRIPTION OF RISK YES NO COMMENTS & ACTIONS
 
Scaffolding
Is the condition of the scaffold acceptable and the relevant local standards for scaffold?
Has proper access been provided?
Are platforms of sufficient width, secure and complete?
Is comprehensive edge protection in place – handrail, mid-rail, and toe-board? (Mesh /
safety net where applicable?)
Are suitable baseplates provided?
Are High Voltage clearances maintained?
Maintain good housekeeping at work locations
Safety nets & Edges of buildings
Safety nets fixed at the bottom of scaffold to prevent bodily injuries in case of fall
Check hard barricading along the edges of buildings.
Ladders:
Strong materials used and well maintained
Ladder not placed against loose boxes, round materials. objects, near electrical installation
Ladder of sufficient height used, on top tied and positioned at the foot of ladder.
Ladder placed at an angle of 70 ‐75 degrees .(i.e. 1: 4 ratio)
Check ladder should be free from slippery substances.
Plant & Electrical Equipment
Has all equipment been listed in the relevant register and fitness certificate/tag provided as
per local legislation?
Are all guards in place?
Has electrical equipment been tested and tagged?
Are electrical leads clear from metal scaffold?
Is power being sourced from the same level/floor?
Is RCD/ELCB (mechanical) protection in place?
Personal Protective Equipment
Is all relevant PPE available and serviceable?
Do harnesses, belts, ropes etc. have current log books / inspected?

COMMENTS:

SIGNED: ……………………………………………(CONTRACTOR SUPERVISOR )

Approval for Work at Height: Granted / Declined.

SIGNED: ……………………………………………( CONTRACTOR SITE IN CHARGE) SIGNED: ……………(CONTRACTOR SAFETY IN CHARGE)

IF DECLINED, ACTION REQUIRED BY SUBCONTRACTOR WITH AGREED TIME LINE

ACTION COMPLETED - APPROVAL GRANTED

SIGNED: …………………………………………(PERMIT REVIEWED BY ENGINEER)

PERMIT EXTANTIONS:

THE EXTENSION OF PERMIT IS GRANTED FROM ________TO _________ NAME & SIGNATURE OF PERMITTEE……………………..

SIGNED: ……………………………………………( PERMIT REVIEWED ENGINEER)

PERMIT CLOSURE:

THIS PERMIT IS CLOSED ON …………..…HRS. DATE: _____/_____/____ NAME & SIGNATURE OF PERMITTEE……………………..
Procedure:
1. A separate permit has to be completed for each and every height work activity.
2. Maximum approval period is one day / one shift
3. This work permit must be completed by the work supervisor and then be reviewed & signed by Contractor representative.

Note: - A copy of this work permit must be available at the work place adjacent where the work is being conducted.

Document Name: Version Correct as at: Page No.

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