Working at Height Permit
All applicable work at height legislative requirements MUST be satisfied
before this permit is issued.
For assistance with determining these requirements consult with senior management or
issuing officer. The condition of issue MUST be complied with for the duration of work.
ALL WORK IS TO CEASE ON THE SOUNDING OR RAISING OF A FIRE OR EMERGENCY ALARM
Permit Details
Reference:
Date:
Time:
Permit Holder
Reason for Permit (Description of work):
Location of work:
Business Name:
Permit is valid from date and time:
Permit valid until, Date and time:
Prestart Review
Y
N
Has a work at height risk assessment been created?
Has the highest practicable level of control been chosen for the
risks identified?
Has a work at height rescue plan been submitted?
Permit Holder
PPE
Required
Safety
Harness
Safe line or
lifeline
Eye/Hand
protection
Safety Boots
Safety
Helmet
Protective
Clothing
Y
N
Other
Control
Measures
Barricades
Warning
Signs
Exclusion
zones
Tool tethers
Kickplates
Conductive
weather
conditions
Y
N
Permit Holder
Equipment Checks
Y
N
Y
N
If permanent anchor points are in place is the inspection
date current?
Does the fall arrest equipment to be used have a current
inspection tag attached?
Are ladders in good working order, and insulated if there
is a potential exposure to electrical energy?
Equipment to be carried is secured to a belt or hoisted up
separately?
Have personnel been trained and deemed
competent for working at height
Has the personnel at work got an in-date work at height
certificates?
Have the personnel at work completed work at height
rescue training, or supervision in place for rescue?
Are rescue and training records up to date and in date?
Is supervision (if required in place)?
Does the personnel feel medically fit and able to perform
the task?
Permit issuer
and Holder
Permit Authorisation
I hereby approve the work to proceed (as listed above), and I agree that the precaution
ns as stated here provide adequate protection for the employees undertaking the job.
Name of permit issuer:
Signature:
Date:
My signature acknowledges that I understand the conditions of this permit and agree to
abide by them:
Name of Permit holder:
Signature and date:
Name of worker:
Signature:
Date:
Name of worker:
Signature:
Date:
Name of worker:
Signature:
Date:
Name of worker:
Signature:
Date:
Name of worker:
Signature:
Date
Non-Compliance
or issues arising
Feedback
Permit Holder
Finalisation (After Completion)
As permit holder I have ensured that all workers have removed their
locks and tags and ensured the work area is clean, tidy, and secured:
Name of permit holder:
Signature:
Date: