WORK AT HEIGHT PERMIT COPY PERMIT NO:

Project: Bangladesh Greater Dhaka Sustainable Urban Transport Project (BRT, GAZIPUR- Airport)
Section: A: Scaffolding Formwork Re-enforcement concreting Roof works Lift works Finishing Works

others work at height activity:

Work at height Activity details:

Company: Location:

Permit valid: Permit valid from Date: Permit Valid till Date:

Section B: Hazard Identified: To be completed by Job Performer, Permit Issuer & Permit Approval.

Identify Potential Hazards:

Fall from Height Collapse of structure Missing Edge Protection No Lifeline/anchorage point
Slip /Trips Hazard Lifting Hazard missing toe board Non-Compliance - Harness
Improper Access//Egress Poor Visibility / Illumination Protruding / sharp object Loose Material on
Improper working platform Manual Handling Hazard Material Falling Hazard Poor Supervision
Material falling hazard adverse weather conditions, Untrained operatives Untied tools
Improper/No Barricading Public Unauthorized Entry Simultaneous operations Loose Material
:
Section C: Identified HSE Control Measures: To be identified by Job Receiver, Permit Issuer & Permit Approval

Documents/Permits/Control Scaffold/proper working platform Personal Protective Communication

Method Statement (MS) Equipment third party certificate Equipment PPE hand tools tied
Risk Assessment(RA) Scaffolding scaff tag system Full Body Harness. Supervisor Presence
Tool Box Talk Midrail Hand rail Safety shoes Material Secured.
Safety Induction anchorage point/Lifeline Visibility vest Toe Board
work at Height Trained Rescue Arrangements. Safety Helmet Safety Net
area Barricades traffic Controller Hand Gloves Public Protection
Signage

Section D: Acceptance, Validity, Approval, Extension : Completed by Job Performer, Permit Issuer& Permit Approval
Work site inspected, identified controls measures are in place, hazards and control measures communicated to workers and
permit conditions are satisfactory.

Date Date Date Date Date Date Date

Permit Concern Party

Job Receiver
Supervisor/ FM/( Sign )

Permit Issuer
Engineer ( Sign )

Permit Approval(HSE)
Safety Officer (Sign )

Section E: Permit Close Out (To be completed by Job Performer & Permit Issuer and Permit Approval )
Work is incomplete, Close and Issue new permit Work is completed, area is safe /secured. Close this Permit.
Name Signature Mobile No

Permit Receiver

Permit Issuer

Area Safety Officer