Work at Height Permit

Work at Height Permit

Property: / Date:
Risk Management
(all boxes to be ticked)
Risk Assessment Form Completed (please attach)
Safe Work Method Statement (SWMS) completed (please attach)
Contractor Details:
Company Name:
Phone:
Site Representative:
Description of Work:
Location of Work:
Works being carried out on behalf of:
Contact Name:
Work at Height Access Method (please if used)
Temporary Ladders (extension or step)
Is the ladder rated for industrial use? / Yes / No / N/A
Is the ladder manufactured to Australian Standards? / Yes / No / N/A
Is the ladder in good working condition (e.g. rungs, steps, rails, braces, ropes, hinges, feet, etc)? / Yes / No / N/A
If the persons and/or vehicles are in close proximity, controls in place? If “Yes” details are required in the SWMS / Yes / No / N/A
Is the ladder secured during use? If “No” details are required in the SWMS / Yes / No / N/A
Scaffolding
Has gradient, height, access and load, been considered for the type of scaffolding to be used? / Yes / No / N/A
Confirm that the person erecting the scaffolding is qualified for over 4 metres in height? / Yes / No / N/A
Have operator ladders and guard rails been erected to prevent fall? / Yes / No / N/A
If persons and/or vehicles are in close proximity, controls in place? If “Yes” details are required in SWMS / Yes / No / N/A
Elevated Work Platform (EWP)
Has gradient, height, access and load been considered for the type of EWP to be used? / Yes / No / N/A
Are only qualified persons operating the EWP machine used? / Yes / No / N/A
Confirmation that the EWP is within the current certification? / Yes / No / N/A
Will fall arrest full body harnesses be worn and connection to prevent fall? / Yes / No / N/A
Confirm that there are no overhead power lines which need insulation prior to work commencing. If “Yes” details are required in the SWMS / Yes / No / N/A
If persons and/or vehicles are in close proximity, controls in place? If “Yes” details are required in the SWMS / Yes / No / N/A
Heights
If above 2 metres, was a safety harness/lifelines used? / Yes / No / N/A
If above 5 metres, has local Work Authority (e.g. WorkCover in NSW) been notified? / Yes / No / N/A
Safety Check List
Contractor at all times will ensure and comply with all relevant safety requirements / Yes / No
Ensure work is carried out in such a manner that it would not endanger people or cause damage to the equipment / building. / Yes / No
Has the area been cordoned off with warning signs / ribbon/ tape? / Yes / No
Maintain good housekeeping at all times / Yes / No
Debris generated must be disposed of from off the site immediately / Yes / No
Agreement
Compliance Agreement by Contractor
I have read and understood the above requirements. I and/ or my representatives agree to abide to these requirements.
Name of Contractor representative:
Signed / Date:
Name of Building Management permit issuer:
Signed / Date