Work at Heights Permit
Description of work
Notes
Location
Notes
Platform Ladder not to be used within two (2) meters (angle of repose) of edge protection guardrails unless
Extended height guardrail fitted to the area if working using a platform ladder, and / or
Yes
No
N/A
Notes
A safety prop is fitted to the platform ladder (if extended height guardrails not installed), and
Yes
No
N/A
Notes
Falling object control measures are in place, and
Yes
No
N/A
Notes
Works are recorded in a site specific safe work method statement?
Yes
No
N/A
Notes
Mobile scaffold used within two (2) meters of edge protection guardrails
Are edge protection guardrails in place?
Yes
No
N/A
Notes
Is the scaffold suitable for the task (i.e. can the appropriate guardrails be installed)?
Yes
No
N/A
Notes
Is the work platform height above three (3) times less base width of the mobile scaffold? If yes then a safety prop, outrigger bracing or fixing tie is required for the mobile scaffold.
Yes
No
N/A
Notes
Has the person been trained in the erection of the mobile scaffold? (High Risk licence required where a person or object has the potential to fall 4 metres or more).
Yes
No
N/A
Notes
Can personnel access the mobile scaffold in a safe manner without any potential fall hazards?
Yes
No
N/A
Notes
Are falling object control measures in place?
Yes
No
N/A
Notes
Are works recorded in a site specific safe work method statement?
Yes
No
N/A
Notes
Elevated Work Platforms (scissor and boom lifts) used within two (2) meters of a live edge.
Are physical barriers in place when used within 2mtrs of live edge?
Yes
No
N/A
Notes
If No to above, are additional control measures following the hierarchy of control recorded in a site specific safe work method statement?
Yes
No
N/A
Notes
Can the suspended concrete slab / ground surface (angle of repose) support the weight of the elevated work platform?
Yes
No
N/A
Notes
Has the operator been trained in the operation of the elevated work platform?
Yes
No
N/A
Notes
Are falling object control measures in place?
Yes
No
N/A
Notes
Access Equipment (Harness & Lanyard)
Is the access equipment to be set up for travel restraint or fall restraint?
Yes
No
N/A
Notes
For fall restraint, rescue procedures must be developed
Yes
No
N/A
Notes
Have personnel be trained in the inspection, set up and use of the access equipment?
Yes
No
N/A
Notes
Is documentation available that access equipment has been inspected by a competent person?
Yes
No
N/A
Notes
Has suitable anchor point been established?
Yes
No
N/A
Notes
Is the access equipment suitable for the task?
Yes
No
N/A
Notes
Are falling object control measures in place?
Yes
No
N/A
Notes
Are works recorded in a site specific safe work method statement?
Yes
No
N/A
Notes
Work Areas with Visual Barricades Only (edge protection removed)
Is the work platform less than a seven (7) degree slope? (If NO edge protection must be in place)
Yes
No
N/A
Notes
Are visual barriers installed a minimum of two (2) meters back from all live edges?
Yes
No
N/A
Notes
Is safe access available to the work area?
Yes
No
N/A
Notes
Are falling object control measures in place?
Yes
No
N/A
Notes
Are rescue procedures established and documented in the event of an emergency?
Yes
No
N/A
Notes
Are works recorded in a site specific safe work method statement?
Yes
No
N/A
Notes
A-Frame Step Ladder extraordinary use requirements
Has the site manager given consent for an A-Frame step ladder to be used?
Yes
No
N/A
Notes
Are works required for using an A-Frame step ladder covered in a SWMS?
Yes
No
N/A
Notes