Document No.
:
Version:
WORKING AT HEIGHTS PERMIT
Issue Date:
Review Date:
Permit Number: Date:
Exact Location of the Job
(Print) :
Description of the Job (Print) :
Company undertaking the Job
(Print) :
Approving Duty Manager: Name: Signature:
THESE PRECAUTIONS MUST BE MET OR CONSIDERED PRIOR TO ANY WORK COMMENCING
Item Description Yes No
A Risk Assessment must be completed prior to work at height being
1
conducted.
Mandatory Tasks / Must be Completed
A Rescue plan must be developed identifying recovery procedure and
2
equipment required.
If Fall Protection Equipment is required the Critical Factor Calculation must
3
be completed.
All personnel working at height must have completed Safe Working at
4
Heights training.
5 Has the ‘working at heights job procedure’ been followed?
Has the personal fall protection equipment been inspected and in good
6
order?
7 A safety observer is required.
Is a copy of the Risk Assessment, rescue plan and ‘critical factors’ calculation
8
attached to this permit?
9 Will starting this work create another hazard with other work in progress?
10 Is barricading required?
11 Are communication requirements in place?
12 Has isolation been completed?
Author : Garry Ross
Approved by : WORKING AT HEIGHTS PERMIT Page 1 of 4
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Document No.:
Version:
WORKING AT HEIGHTS PERMIT
Issue Date:
Review Date:
SPECIAL INSTRUCTIONS OR CONTROL MEASURES:
Issued by Authorised Person Permit Valid From: Permit Expires:
Issued By Name Date Time Date Time
(Print):
Signature: / / : / / :
Accepted by Person/s in Direct Control of Work Notes: Permit Location:
Accepted by Note: WORKING AT Permit must remain at
Name (Print): HEIGHTS Permit is only job site while work is in
valid when person in direct progress and then
control of work is at the returned to supervisor for
Signature:
work site filing
Persons Working at Heights
Print Name: Signature: Safety Observer: is the nominated competent person
who shall perform the task of safety watch while others
are working at heights. This person shall not perform
any other work while acting as the Safety Observer. This
person shall have a Safe Work at Heights certificate, a
minimum of first aid training and be competent in the
use of the recovery equipment being used.
Safety Observers
Print Name: Signature:
Rescue Plan
Author : Garry Ross
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Document No.:
Version:
WORKING AT HEIGHTS PERMIT
Issue Date:
Review Date:
In the event of an emergency where the rescue of an employee is required from working at heights the following
plan is to be applied by the stand by person or safety observer.
Permit Number: Date:
Description of the Job (Print):
Person in direct control of work:
Standby Person / Safety Observer
Recovery Procedure: (who, what &
how)
Author : Garry Ross
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Document No.:
Version:
WORKING AT HEIGHTS PERMIT
Issue Date:
Review Date:
CHECK LIST
Item Description Yes No Comments
1 Working at heights permit
2 Trained and authorised personnel
3 Risk assessment / JDA
4 Rescue plan understood by all
5 Personal protection equipment
6 First aid kit
7 Two way radio
9 Rope rescue device
10 Elevated work platform
11 Man basket and crane
12
13
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Any other equipment required for the rescue?
Note: Attach this rescue plan, risk assessment and any other additional documentation to the permit
Approving Manager – Name & Date
Signature
Note:
Task manager or person in direct control of work will obtain manager sign off. The permit must be kept at the
work site for the duration of the work at heights.
A copy of the permit shall be held by the authorized person for a period of 12 months or filed with their
department manager.
Author : Garry Ross
Approved by : WORKING AT HEIGHTS PERMIT Page 4 of 4
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