Work at Height Permit CONTRACT No.

(For high risk working at height i.e. works on fragile surfaces and areas where provision of edge PERMIT No.
protection is not practical) PROJECT/ SITE

ALL WORK UNDER THIS PERMIT IS VALID FOR A SINGLE ACTIVITY AND PER SHIFT

REQUESTED BY (Supervisor) DATE & TIME DURATION

CONTRACTOR
SPECIFIC WORK LOCATION

DESCRIPTION OF WORK/ HAZARDS etc.

(e.g. Sheet installation on roof without edge

protection, fragile roofs )

FALL PROTECTION SYSTEM PROVIDED:

(include- Fall arrest/ fall restraint system,

connection devices e.g. temporary lifelines
and full body harness with double lanyard
and shock absorbers, advanced edge
protection, safety nets etc)

Emergency Rescue Arrangements (Provide

details of arrangement, Names & number of
person(s) involved and equipment for the
shift)

EQUIPMENT IDENTIFICATION. (Mention ID

numbers of all fall arrest systems and
connecting devices provided)

Requirement Yes No N/A Requirement Yes No N/A

Exclusion zone has been established below with a full time watch
Fall arrest system has been designed by an independent body and
man positioned to control and restrict access to the area. (Mention
checked to be satisfactory by the temporary works coordinator.
name)

Connecting device (full body harness, inertia reel) is in good

condition, third party certified, free from any defects and inspected by All operatives involved have been trained for working at height.
competent person.

Work at Height Conditions (Must be Fall prevention plan has been communicated to all operatives
All operatives have been provided with tool tethers.
completed by Supervisor and verified on site involved.
by Permit Authoriser)

Fall arrest system has a valid permit to load/ use signed off by the Activity briefing is conducted by the supervisor at place of work.
temporary works coordinator. (attach to this permit)

Operatives and rescue team briefed on approved MSRA, PTW

Safe access is provided to work area.
requirement and rescue arrangements.

Access is restricted with signs & controls to prevent unauthorised Where risk assessment has identified, anti-slip safety boots or safety
access. mats have been provided.

ISSUE

_______________________
I ….Supervisor …………………………(Permit requestor) confirm that this Work at Height requirement have been checked and recorded at work location. Signature, Date & Time
I will ensure all operatives are briefed on Permit to Work requirements and the activity.

_______________________
I ……..Site/ Construction/ Project Manager …. (PTW Authoriser) confirm to authorise the Work at Height in …………………………(mention exact location ) as detailed in this Permit. Signature, Date & Time
I confirm that I have physically checked work location and all Work at Height conditions is satisfactory.

HAND-BACK/ CLOSE OUT (Must be completed by Supervisor/ Permit requestor and returned to Permit Coordinator)
Work is completed at (Time & Date): ………………….

All equipment have been stored correctly.

_______________________
I ….Supervisor …………………………(Permit requestor) confirm that the work is completed and have checked that access is restricted to any persons.
Signature, Date & Time

SUSPENSION/ CANCELLATION
Where monitoring of any type identifies contractor works which are not adequately covered by a Health and Safety MS/RA, all or specific parts of those works will be immediately suspended by the Supervision Consultant and/or the Employer until
satisfactory action is taken by the contractor to rectify the situation.
During the excavation process, works must immediately stop and further guidance must be obtained if any variance of services or conditions are found.
Conditions observed for suspension/ Cancellation of Permit:

NAME: ……………………………. SIGNATURE .............................................. DATE .................................

SOP-355 ATT. 7.8 Rev 5

# Classification - Public