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Elevated Work Permit

ELEVATED WORK PERMIT


Project Name:
Project Start Date:
Subcontractor Companies:
TRACKing the Elevated Work Permit
Check all the apply
Elevated
Work
Qualified
Competent
Person
Experienced
Can Work
Alone
Short
Service
Employee
Training
Required
Supervision
Required
RECOGNIZE THE HAZARDS (check those that apply) and ASSESS THE RISK (Low - Moderate - High)
YES NO SELECT YES NO
SELECT

Project Location:
Date:
MATERIALS OR TOOLS AT
HEIGHTS
LIFTING, PUSHING OR PULLING
WORK NEAR ELECTRICAL LINES
MANUAL HANDLING MATERIALS
MOVING MATERIALS
OVERHEAD OBSTRUCTIONS
WORKING ABOVE A HAZARD
WORKING ALONE
GROUND LEVEL OBSTRUCTIONS
Job Task: (Summary of what elevated work is proposed)
THINK THROUGH THE TASK
Permit Developed By:
Client:
Company
Project Completion Date:
Client Contact:
WORKFORCE INVOLVED IN ELEVATED WORK
Name
Comments/Additional Details:
WEATHER OR TEMPERATURE
FALLING OBJECTS
LACK OF SPACE
FRAGILE ROOF OR SURFACES
FALLING OBJECTS
SLIPS, TRIPS, FALLS
UNGUARDED EDGES
UNEVEN FLOOR SURFACES
POSSIBLE FALL FROM A HEIGHT OF 6' (1.83M)
OR MORE
POSSIBLE FALL FROM A HEIGHT BELOW 6'
(1.83M)
POSSIBLE FALL FROM A LADDER
POSSIBLE FALL FROM A WORK PLATFORM
POSSIBLE FALL INTO A HAZARDOUS SUBSTANCE
POSSIBLE FALL INTO EXCAVATION
POSSIBLE FALL INTO WATER
RESTRICTED SPACE
VEHICLES OR TRAFFIC
Fall Protection ARCHSFS007 24 February 2011 1
Elevated Work Permit
CONTROL THE WORKING ENVIRONMENT
YES NO YES NO
CONTROL THE HAZARDS: TYPE OF FALL PROTECTION SYSTEM TO BE USED
YES NO YES NO
EQUIPMENT REQUIRED
Personal Fall Arrest System YES NO YES NO
Positioning/ Restraint System YES NO YES NO
YES NO
KEY ITEMS CHECKLIST
YES NO N/A
YES NO N/A
COVERS
CONTROLLED ACCESS ZONE
FENCES
BARRICADES
CAGE LADDER SYSTEM
RIGID RAIL
WIRE RAIL SYSTEM
WARNING LINE SYSTEM
Guardrail System
SAFETY NET
POSITIONING DEVICE SYSTEM
Note: General Industry requires fall protection at heights of 4 feet and greater, whearas Construction Industry requires
protection at 6 feet and higher.
FALL ARREST (INSPECTED)
HARNESS (INSPECTED)
LADDERS
AERIAL LIFT/ MAN LIFT/ SCISSOR LIFT
Other Equipment
RAMPS/STAIRWAYS/STEPS
DOUBLE LANYARD FOR 100% TIE-OFF
FALL RESTRAINT (INSPECTED)
Is a Qualified Person available for assistance if needed?
Are midrails being used with guardrail systems?
GUARDRAILS
PFAS
LADDER PLACED AT 4:1 ANGLE
THREE FEET OF LADDER ARE ABOVE
STEPPING-OFF POINT
ISOLATE EQUIPMENT
FIRST AID PROVISION
RESCUE AT HEIGHTS AVAILABLE WITHIN
FIVE MINUTES
SAFE WORKING AREA WORK EQUIPMENT INSPECTED
LADDER SECCURED AT TOP AND ON
LEVEL FIRM BASE TO SUPPORT LOAD
WEATHER
MID-RAIL PLACED WITH NO GAP OF 19"
(48cm)
GUARD RAILS (DOUBLE ABOVE 6'
[1.83m])
GUARD RAILS (TOP RAIL A MINIMUM OF
39" [1m] ABOVE PLATFORM)
TOE BOARDS
6' (1.83M) FALL-LIMITING LANYARD WITH
SHOCK ABSORBER
ANCHORAGE POINTS DESIGNED
Will guardrails withstand a 200-pound force from an outward or downward direction?
Are openings on safety nets no greater than 6-inch squares?
Does warning line have a minimum tensile strength of 500 pounds (2,220 N)?
Is warning line capable of supporting, without breaking, loads applied to the stanchions?
EQUIPMENT MAINTAINED
Fall Protection Systems
Fall Protection Program
Has a Competent Person been designated?
Have employees received training (site specific as needed) by a Competent Person?
TAGGED
FIXED SCAFFOLDING ERECTED BY CP
Scaffolding
Are toeboards being used with guardrail systems?
GENERAL INDUSTRY PROJECT
CONES/BARRIERS
EMERGENCY RESCUE PROCEDURES IN
PLACE
CONSTRUCTION INDUSTRY PROJECT
Fall Protection ARCHSFS007 24 February 2011 2
Elevated Work Permit
YES NO N/A
YES NO N/A
YES NO N/A
Emergency Contact:
*Include any Task Specific JLAs with this permit.
KEEP H&S FIRST IN ALL THINGS
APPROVAL OF ELEVATED WORK PERMIT- By ARCADIS Competent Person:
Name: __________________________________________
Title: ___________________________________________
Office Location: ___________________________________
Date: ___________________________________________
I understand the nature of the work for this permit, and certify that this permit meets the requirements specified in the
ARCADIS Elevated Work and Fall Protection Standard.
Work Care
Phone 1:
800-455-6155
H&S Manager:
Are horizontal lifelines designed to support 5,000 pounds for each employee attached?
Is no more than one employee being attached to a single vertical lifeline?
Are personal fall arrest systems being adequately inspected before each use?
Do they automatically limit free fall distances to 2 feet?
Are they capable of sustaining a tensile load of 3,000 pounds (13.3 kilonewtons)?
Are self-retracting systems being inspected before and after each use?
Self-Retracting Lifelines
Rescue Plan
Local Ambulance:
Location: Phone 2:
Local Fire Dept.
Site Safety Officer:
Project Manager:
Site Manager:
Client Contact:
Local Police:
Has an effective rescue plan been developed?
Have personnel been trained in the rescue plan?
Are only full body harnesses being used?
Are lanyards with a deceleration device being used?
Are only double-locking safety-type snap hooks being used?
Are anchorage points capable of supporting 5,000 pounds (22.2 kilonewtons)?
Are horizontal lifelines engineered by a Qualified Person?
Personal Fall Arrest System
EMERGENCY CONTACT LIST
Are positioning devices used for fall protection?
Are covers appropriately marked or adequately fastened?
If a fall protection plan is in use, has it been developed by a Qualified Person?
Fall Protection ARCHSFS007 24 February 2011 3