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Form - WAH or SCAFFOLDING Rev. Dec2016

This document is a Permit to Work at Height, required for all high-level work above 13 feet or 4 meters. It outlines necessary procedures, safety equipment, and worker competency requirements before commencing work. Additionally, it includes sections for authorization, completion verification, and emergency contact numbers.

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Mohd Khairul Md Din
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22 views2 pages

Form - WAH or SCAFFOLDING Rev. Dec2016

This document is a Permit to Work at Height, required for all high-level work above 13 feet or 4 meters. It outlines necessary procedures, safety equipment, and worker competency requirements before commencing work. Additionally, it includes sections for authorization, completion verification, and emergency contact numbers.

Uploaded by

Mohd Khairul Md Din
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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PERMIT TO WORK AT HEIGHT (GENERAL)

SERIAL NO: NAME OF COMPANY: ________________________

This Permit must be used for ALL HIGH LEVEL WORK (Above Than 13 feet or 4 meter)
This permit must be displayed at the work site at all times & returned upon completion of work
APPLICATION FOR PERMIT TO WORK AT HEIGHT (WAH)
Date of work: Time of work:
Contractor/Internal Dept Performing Work:
Contact Name: Phone: (mobile)
Location of Work:
Description of Work:

Equipment to be used:
Certificated Machinery to be used (If applicable) :
Name of Worker(s): 1 3 5
2 4 6
* Please Provide Workers List with their ID's and Position
WO NO: (If applicable)
BEFORE PROCEEDING
Elements Procedures
1. Method Statement submitted and approved. a. Written Statement on How Works will be executed.
b. To be submitted to EHS Section/Dept. Person In Charge (PIC)
c. To be review by EHS Section/Department PIC.
2. All workers should be equipped with PPE. a. PPE use should be suitable & practicable for Working at Height.
* Safety Harness, Safety Helmet, Safety Shoes and etc. * Only full body harness is acceptable for Working At Height.
b. To check and verify the PPE used is safe & free from any defect.
3. Ensure suitability & safety of Equipment/Material a. Winch/Scaffolding/Ladder.
/Machinery used as per Local & International Standard. b. Sling/Rope/Hoisting Cable.
c. Anchorage Point/Hook Point.
d. Safety Harness Connector.
4. Opening edges & floor openings provide with the a. All opening edges & floor opening to be barricades either
Barricades or Guardrails. (If applicable) temporarily or permanently as to prevent from falling down.
5. Competency of Contractor Supervisor & Workers a. Competency for Working At Height.
b. Competency for Working with a Gondola/Scaffold.
c. Trained on how to use the PPE effectively.
6. Briefing on PAVILION EHS Requirement & Procedures a. To be conducted by PIC if they are Competent for WAH or
for WAH Conducted to All Contractor Supervisor b. Conducted by EHS Section Personnel.
and Workers.
7. Any other special conditions and comments :-

DEPT. PERSON IN CHARGE/SAFETY & HEALTH OFFICER ACKNOWLEDGED BY


The above work is authorised to proceed subject to the following action being taken prior to work starting and CONTRACTOR/SUPERVISOR
procedures being maintained for the duration of the work. Each item is to be checked and verify by the Authorised
Department Person In Charge and EHS Section Personnel (SHO) prior to work starting for each activities related to Signed:
Working At Height.

EHS Section Personnel (SHO) : Name: _________________________

H/P No. :
Name: __________________ Sign : ___________ Tel : __________ Off. No. :
WORK COMPLETED & AREA SAFE
The work area has been inspected and checked after completion of work:
Dept. PIC/EHS Section Personnel : Contractor/Supervisor :

Signed: ____________________ Date: __________ Signed: ____________________ Date: __________


Name: _____________ Emp. No. : ______________ Name: _____________
STOP WORK ORDER CONTACT NUMBERS
Stop Work Order (SWO) is issued by : Security : 017 - 692 5055
Name : ____________________ M&E : 017 - 388 4423
Signed : ____________________ OSS : 017 - 229 9867
Department : ____________________ EHS : 017 - 692 6927
DOs and DON'Ts are listed at the back for compliance
Date : ____________________ cc: EHS (Briefing by contractor to EHS before commencement of work)
SWO being issued due to : M&E, OSS
___________________________________________________
___________________________________________________
___________________________________________________

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