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WORKING AT HEIGHTS PERMIT

PERMIT NO.: Permit starts: / / . . am/pm Permit issued by: Signed: / / Employer: ____________________________________ Address: ____________________________ __________________________ __ __ __ __ Tel. ( ) RISK ASSESSMENT NO.: Permit ends: / / . . am/pm Person in charge: Signed: / / Owner of workplace(s): ____________________________________ Address: ____________________________ __________________________ __ __ __ __ Tel. ( )

DESCRIPTION OF WORK TO BE CARRIED OUT Note: Only the work listed below may be carried out under this permit: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

PERMIT NO.:

CONTROL MEASURES TO BE IMPLEMENTED

REQUIREMENTS AND ARRANGEMENTS FOR WORK AT HEIGHTS Note: The whole of the remaining detail of this permit must be completed and signed by the authorising person(s) before work is to proceed. ISOLATION OF HAZARDS The items ticked below have been isolated or made safe: (cross out non-applicable items) Pipelines (water, steam, gas, fuel, etc) Mechanical and/or electrical drives Traffic flow in work area suspended or controlled Electrical services Air-conditioning and exhaust ducting Other (specify): Warning notices, locks or tags have been fixed to all means of isolation Authorised person: Date: / / FALL PREVENTION MEASURES The fall prevention measures below have been implemented: Barriers or barricading of work platforms Use of safety harnesses Inertia reels or lifelines Authorised person: Date: / /

8.40 Confined Space Entry Permit

PERMIT NO.:

CONTROL MEASURES TO BE IMPLEMENTED

MEANS OF ACCESS TO WORK AT HEIGHTS Scaffolding (type): Height access or reach equipment (type): Other (specify): WORK AT HEIGHTS PROCEDURES The following precautions must be observed when working at heights: Scaffolding over 4 metres high to be erected by licensed scaffolder only Scaffolding to be inspected by competent person daily before use Mobile scaffolding to have wheels securely locked before work commenced Area which may be affected by work at heights to be barricaded off All sparks from work more than 2 metres above ground or floor level must be contained completely by use of suitable enclosure which must be inspected before work Area must be clean and free of readily combustible materials within ___ metres Power leads not to be draped across scaffolding or access ways Tools, equipment, etc, to be secured from falling by lanyards Kickboard to be provided around perimeter of work platform to prevent materials, tools and equipment falling from platform Need for observer to be considered, and appointed if necessary Other: Authorised person: Date: / / SIGN ON / SIGN OFF Name: Name: Name: Date: / / Date: / / Date: / / Time on: am/pm Time on: am/pm Time on: am/pm Time off: am/pm Time off: am/pm Time off: am/pm Signed: Signed: Signed: Name: Name: Name: Date: / / Date: / / Date: / / Time on: am/pm Time on: am/pm Time on: am/pm Time off: am/pm Time off: am/pm Time off: am/pm Signed: Signed: Signed: Name: Name: Name: Date: / / Date: / / Date: / / Time on: am/pm Time on: am/pm Time on: am/pm Time off: am/pm Time off: am/pm Time off: am/pm Signed: Signed: Signed: WORK COMPLETED OR SUSPENDED All personnel have been withdrawn from the work area All tools and equipment have been/not been removed from work area All work at heights has been completed/suspended Work area is/is not fit for use. Other: Authorised person: Date: / / RECORD OF SIGN OFF All persons have exited the height work area. Authorised person: Date: / / PERMIT NO.:
8.40 Confined Space Entry Permit

CONTROL MEASURES TO BE IMPLEMENTED

COMMENTS REGARDING WORK CARRIED OUT Provide comments about the work carried out which may relate to similar work:

Authorised person:

Date:

REVIEW OF WORK PROCEDURES The following aspects of work require review before similar work is undertaken:

Authorised person: VERSION HISTORY Details of amendment

Date:

Version

Prepared by

Date of issue / / / / / / / / / / / / / / / /

8.40 Confined Space Entry Permit