WORK AT HEIGHT CHECKLIST

STOP if not clear how to do the work. Use before a worker/crew begins an activity where
worker’s feet are more than 1.8 meters above grade, floor or surface
Company Name:CINQO CONTRACTING Project Name:
Location/ Area: Date:
Sr.N STATUS
ITEMS CHECKED
o YES NO REMARKS (IF ANY)
1. All workers are trained for work at height
2. Walkways provided with handrails, mid-rails, and toe guards?
Use of fall protection when erecting or dismantling scaffold at
3.
heights >1.8 metres?
4. Platforms and walkways free of oil/grease or other slippery spillages?
5. Is the work area sufficient illuminated?
6. Slip and Trip hazards are identified and proper controls are in place?
7. Safe Access and Egreess available?
8. Temporary work platform is made and safe to use?
Use of safety helmet, safety belts / full-body harness ensured for all
9.
workers.?
10. Are all Full Body Hraness (FBH) inspected ?
Are all workers trained to how to use the FBH and instructed to wear
11.
& attach FBH to the lifeline OR anchoring point?
Common lifeline provided where ever linear movement at height is
12.
required.
13. Is there any risk from overhead electricity cables?
14. Other (if any)
Report if any above items are not meeting the standard/ specific requirements to the discipline engineer and safety department.

DECLARATION & SIGNATURE

I have reviewed this Checklist and all other work arrangements with all other workers
involved in this work I confirm that adequate safe systems of work will be maintained and
that all of the required precautions for Working at Heights will be undertaken, and the
information provided in this form is true and accurate.

আমরা এই কাজের সাথে জড়িত অন্যান্য সমস্ত কর্মীদের সাথে এই চেকলিস্ট এবং অন্যান্য সমস্ত কাজের ব্যবস্থা
পর্যালোচনা করেছি আমি নিশ্চিত করি যে কাজের পর্যাপ্ত নিরাপদ ব্যবস্থা বজায় রাখা হবে এবং উচ্চতায় কাজ
করার জন্য প্রয়োজনীয় সমস্ত সতর্ক তা অবলম্বন করা হবে এবং এতে প্রদত্ত তথ্য ফর্ম সত্য এবং সঠিক
 WORK AT HEIGHT CHECKLIST
S.NO NAME SIGNATURE

ACTION NAME SIGNATURE REMARKS – IF ANY

CHECKED BY (FOREMAN)

SITE ENGINEER

REVIEWED BY (FIELD HSE)