WORKING AT HEIGHT PERMIT Permit #:
Working at Heights is defined as where a person is working within 2 metres of an
unprotected edge which exposes them to a fall of 2 metres or more.
Questions Response Action
Can risk be eliminated? Eg. ☐ YES ☐ NO
Can work be done without
working at heights?
Can risk be isolated by ☐ YES ☐ NO
erection of temporary
barrier?
Can Engineering controls be ☐ YES ☐ NO
applied, secure platform,
scaffolding, elevated work
platforms (EWP)?
Are personnel trained and ☐ YES ☐ NO
competent?
Any other hazards in the ☐ YES ☐ NO
area?
SECTION 1 – Specification of Work
Location of Work:
Description of Work:
Date: Time: Duration: hrs
SECTION 2 – Persons Working at Height
I am competent to operate the equipment to be used in this task, I do not suffer from any
condition that may impede my ability to work at height safely. Eg. (vertigo, epilepsy).
Name (Print) Date Signature
SECTION 3 – Authorisation to Work
I accept this Permit, agree to be bound by the conditions detailed above and the associated
procedure(s), and accept responsibility as the person directly in charge of the work.
I have read the attached risk assessment / Job Safety Analysis (JSA), procedures and Rescue
plan and have the observed risk controls in place.
Name Signature Date
I authorise the Work at Heights project to the conditions/precautions of the Risk
Assessment / JSA as indicated on this Permit.
Name Signature Date
SECTION 4 – Completion, Suspension or Cancellation of Work
All work associated with this Working at Heights Permit has been: ☐ COMPLETE ☐
CANCELLED ☐ SUSPENDED
The work area and adjacent areas have been inspected after completion of the work and all
hazards have been made safe: ☐ YES ☐ NO
Additional comments: .............................................................................................................
DPW Site Representative Signature Date cancelled / Time
SECTION 5 – Performance of Work (Use these questions when assessing the
risk)
Can part of the job be performed at ground Can people be excluded from the fall risk
level? area?
Will persons be kept more than 2m from Are alternative walkways and emergency
unprotected edge? egress/exit routes identified?
Is barricading and signage required? All trip hazards identified and controlled?
Equipment suitable for task? Are tools fitted with a lanyard?
Is there a potential for objects to fall from Can objects be prevented from striking
height? people?
• Tools fitted with lanyards • NO GO ZONES
• Debris nets • Overhead protection
• Screened scaffolding?
People trained in equipment use? Do all persons involved have a helmet chin
strap attached?
1. Scaffolding
For scaffolds of a height greater than 4m Pre start and harness inspection and log
the scaffold must be designed and erected book completed?
by ticketed scaffolders and a scaftag
installed.
Is scaffolding in good condition and on Has stability of ground been inspected for
stable ground? approaching plant or passing traffic?
Will scaffolding be sufficient for the task? Any overhead/underneath hazards?
Is the ground level and stable?
Will a standby person be required?
2. EWP
3. Fall restraint/arrest
Have fall restraint and fall arrest Are you using a ladder within the ladder
differences been properly identified and length of a handrail or moving equipment?
suitable equipment selected?
Equipment in good condition, inspected Is ladder in good working order?
and tagged?
Have the working at heights equipment Is the ground level and stable & ladder
requirements been identified? secure from falling over?
If inertia reels are required are attachment
points located overhead and properly
placed and secured?
Are anchor points suitable, anchor points
inspected and serviceable?
Is rescue available for a suspected person
who may fall in a harness?
5. Additional Checks Required/Completed
Additional comments:
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
........................................................................................................................
