Scribd
Upload
363 views

4 Sample Work at Height Permit

This permit outlines control measures for work at heights. It requires identification of the task, location, duration, number of workers, supervision, control measures implemented, hazards identified, and approval signatures from the supervisor, safety assessor, and authorized manager. Upon task completion, the supervisor must confirm the work area has been restored with no new hazards. The permit is displayed during the approved task and removed upon completion or expiry.

Uploaded by

lam dinh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
363 views

4 Sample Work at Height Permit

This permit outlines control measures for work at heights. It requires identification of the task, location, duration, number of workers, supervision, control measures implemented, hazards identified, and approval signatures from the supervisor, safety assessor, and authorized manager. Upon task completion, the supervisor must confirm the work area has been restored with no new hazards. The permit is displayed during the approved task and removed upon completion or expiry.

Uploaded by

lam dinh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Sample Work at Height Permit-to-work

PERMIT TO WORK AT HEIGHTS


Permit No:

This permit shall be displayed for the duration of the approved task and
removed only upon task completion or upon its expiry

SECTION 1: APPLICATION (to be completed by Supervisor)

Task Description:

Location of WAH: Task covers multiple locations


(attach sketch/ map if necessary)

Start/ End Date: Task exceeds 1 work shift


(daily endorsement required)

No. of Workers: No. of Supervisors:

WAH Control Measures Implemented: Y N NA Remarks

Due consideration given to eliminate work at heights tasks

Safe means of access/ egress provided

Edge protection provided wherever there is falling risks

Fall prevention equipment used to provide access/ work platform

Fall prevention equipment are adequate and in good condition

Anchorage/ Lifeline installed and inspected by competent person

Travel restraint system used to exclude persons from falling risks

All persons subjected to falling risks are equipped with PFAS*

All personnel are adequately trained to perform work at heights

Hazards and Risk Assessment conducted and communicated

Others (pls specify):

* Personal Fall Arrest System

I declare that the information provided is accurate and the control measures listed above have been effectively implemented.

Name/ Designation/ Signature: Date:


SECTION 2: EVALUATION (to be completed by Safety Assessor)

Assessment of Control Measures: Y N NA Remarks

All reasonably practicable measures have been taken

Verification of documents/ interview workers/ others

Site Survey with Supervisor:

All persons on site are protected from falling risks

Surrounding areas do not pose additional hazards

Multiple Locations/ Extended Duration:

Hazards are common at various locations/ time period

Control measures are applicable and effective

I have evaluated the application and am satisfied that all reasonably practicable measures have been taken effectively.
Name/ Designation/ Signature: Date:

SECTION 3: APPROVAL (to be completed by Authorised Manager)


Review of Permit: Y N NA Remarks

Proper Permit-to-work evaluation has been completed

No incompatible works that may pose additional hazards

Control measures have been implemented effectively

Fall from heights risks have been effectively mitigated

I authorise the work at heights to the conditions and duration stated in this permit.

Name/ Designation/ Signature: Date:

SECTION 4: TASK COMPLETION (to be completed by Supervisor)


The WAH task has been:
Date/ Time:
Completed
Suspended due to permit expiry
Terminated due to change in condition Remarks:

I confirm that the work area has been restored to its original condition and no new hazards have been introduced.
Name/ Designation/ Signature: Date:

You might also like