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Work at Height Permit
(Authorization to Perform Work at Height)
Permit & Job Details
Company Name
Permit No
Department / Section
Date Issued
Valid From
Valid To
1. Work Description & Location
Exact Location of Work
Approximate Height of Work
Description of Work to be Performed
2. Personnel & Training
Work Supervisor
Name(s) of Work Crew
Are all workers trained for Work at Height?
Yes
No
3. Hazard Assessment & Control Measures
Please check all hazards identified and the corresponding control measures applied.
Fall from height
Falling objects
Unstable work surface
Adverse weather conditions (wind, rain)
Poor access or egress
Overhead power lines / obstructions
Equipment failure (ladder, scaffold)
Other:
Control Measures
Guardrails / handrails installed
Fall arrest system used (harness, lanyard)
Ladder secured and inspected
Scaffold inspected and tagged
Exclusion zone established below work area
Tools secured to prevent falling
Visual/physical barriers installed
Other:
4. Authorization
Permit Issuer Name
Signature
Date
Lead Worker Name
Signature
Date
5. Work Completion & Permit Handover
Completion Time
Date
Work area is clear of tools and materials
Yes
No
Permit Closed By Name
Signature
Date
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