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Permit To Work at Heights

This document is a permit to work at heights that must be completed before any work is done above ground. It requires listing the location and description of works, confirming a safe work method statement is provided, and specifying the equipment, isolated services, control measures, and environmental factors relevant to the job. The permit must be authorized by the issuer and permit holder, displayed at the work site, and signed off when complete to confirm the work area is safe to resume normal operations. It is a 2 page form used by Central Office to authorize and document safe work at heights.

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Vinod M
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289 views

Permit To Work at Heights

This document is a permit to work at heights that must be completed before any work is done above ground. It requires listing the location and description of works, confirming a safe work method statement is provided, and specifying the equipment, isolated services, control measures, and environmental factors relevant to the job. The permit must be authorized by the issuer and permit holder, displayed at the work site, and signed off when complete to confirm the work area is safe to resume normal operations. It is a 2 page form used by Central Office to authorize and document safe work at heights.

Uploaded by

Vinod M
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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No: DEE ESWB 27-8-3

Title: Permit to Work – Work at Heights Permit


Authorised By: Manager ESWB

Issue Date: June 2011 Number of Pages: 2


Last Reviewed: June 2013 CENTRAL OFFICE USE ONLY
Next Review Date: June 2015

Permit Number: Date:


Site:
Location:
Contractor/ Phone:
Employee:
This permit is valid from: am/pm On:
This permit is valid until: am/pm On:
Description of works:

A Safe Work Method Statement (SWMS), Job Safety Analysis (JSA) and/or Safe Work Procedure (SWP)
has been provided and is attached to this ‘work permit’ Yes No

Note: The following section of this permit must be completed and signed by the authorised
person(s) before work is to proceed and only work listed above may be completed.
The following equipment will be used during the works (all equipment to be used is in good working order and is fit for
use):

Elevated work platform Roof and/or ladder anchor


Ropes and harness
(i.e. scissor lift) points
Step ladder Extension ladder Edge protection
Mobile scaffold Appropriate footwear Safety net
Other (please specify):

The following services have been isolated for the duration of the works:
Electrical Outlets /
Smoke / thermal detectors Pipes, tanks and valves
appliances
Other (please specify):

The following control measures have been implemented for the duration of the works:
Barricades Signage Spotter
Other (please specify):

The following environmental factors have been assessed and are suitable for the works:
Weather / wind Stored material / vegetation
Other (please specify):
This permit should be prominently displayed at the work site

Authorisation
Permit Issued To:
(Print name) (Signature) (Date)

Permit Issued By:


(Print name) (Signature) (Date)

Cancellation/completion of permit
Permit cancelled/returned by:
(Print name) (Signature)

Cancelled/returned at: am/pm On:


Reason for cancellation :

Final Sign Off


The worksite has been inspected by me at the cancellation/completion of the work at heights and declared safe for
normal operations to resume.

(Print name) (Signature) (Date)

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