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    Work at Height Permit Form-2020

    Uploaded by

    Ebrahsm Elshenawy
    This work at height permit document outlines the necessary safety precautions, equipment, and approvals required for working at heights. It requires listing the project details, location, tools to be used, identified risks, safety precautions implemented, inspections completed, required personal protective equipment, and signatures of the permit receiver and issuer authorizing the work. Additional precautions may be required and noted, and the permit can be re-validated or suspended as needed with notifications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Work at Height Permit Form-2020

    Uploaded by

    Ebrahsm Elshenawy
    213 views2 pages
    This work at height permit document outlines the necessary safety precautions, equipment, and approvals required for working at heights. It requires listing the project details, location, tools to be used, identified risks, safety precautions implemented, inspections completed, required personal protective equipment, and signatures of the permit receiver and issuer authorizing the work. Additional precautions may be required and noted, and the permit can be re-validated or suspended as needed with notifications.

    Original Title

    Work at Height Permit Form-2020

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    This work at height permit document outlines the necessary safety precautions, equipment, and approvals required for working at heights. It requires listing the project details, location, tools to be used, identified risks, safety precautions implemented, inspections completed, required personal protective equipment, and signatures of the permit receiver and issuer authorizing the work. Additional precautions may be required and noted, and the permit can be re-validated or suspended as needed with notifications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    213 views2 pages

    Work at Height Permit Form-2020

    Uploaded by

    Ebrahsm Elshenawy
    This work at height permit document outlines the necessary safety precautions, equipment, and approvals required for working at heights. It requires listing the project details, location, tools to be used, identified risks, safety precautions implemented, inspections completed, required personal protective equipment, and signatures of the permit receiver and issuer authorizing the work. Additional precautions may be required and noted, and the permit can be re-validated or suspended as needed with notifications.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    You are on page 1of 2

    Contractor LOGO WORK AT HEIGHT PERMIT

    PTW Ref .No: Contractor:


    Project Name: No. of Employees involved
    Starting From Date Time Expected Completion Date Time
    Scaffolding Ladder Aerial Lifts Roof Work Other; Specify:
    Work Description:

    Location of job to be performed:


    Tools/Equipment to be used:
    Identify risk associated with Work At Height
    Fall from Height Adverse Weather Flying particles Moving Vehicle/ Equipment
    Falling Debris/ Objects Protruding objects, parts Tripping / Slipping Faulty Equipment/ Material
    Fragile surface /Roof Work Under Below Near Overhead lines Near energized equipment
    Other(Specify):
    The following document must be attached with this permit
    Method Statement Risk Assessment Job Safety Procedures Other (specify):
    Precaution require to complete the work safely Yes No N/A
    Have the risk control/s been implemented? if yes state below
    Fall Protection : Guard Rails system Safety Net Toe Board
    Fall restraint : Life Line Retractable Harness
    Fall arrest : Harness with Shock absorber & Double Hook
    Have proper access/egress been provided?
    Is wind speed greater than 32 km/h? If yes, do not proceed the activity
    Are all floor openings at roof adequately covered/protected to prevent falling?
    Is the scaffold erected and inspected by Certified person? (if no do not proceed the activity)
    Are the scaffold, ladder, Arial lift inspected it?
    Name of Inspector: Date of Inspection:
    Other (specify):
    The following areas / items have been inspected by issuer and receiver
    Danger/Warning Sign Scaffold Tag System Lighting Safety Barriers
    Buddy System Rescue Material basket Other (specify:
    PPE Required for the activity
    Helmet with Chin strap Safety Shoes Safety Gloves Safety Ear Plugs/muff
    Safety goggles Reflective Vest Dust Mask Safety clothes
    Other (Specify):
    Issue and acceptance before work
    Acceptance of Work Permission by the person in-charge (Receiver)
    I certify that, I have read and verified this work permit and checklist. I have been informed about the risk assessment results. I am aware of the
    risks that can be exposed to. I commit that I will be in line with all safety rules mentioned in work permit checklist and will not deflect any of
    them.
    Permit Receiver Name: Signature/Date:
    Authority to proceed by authorized person (Issuer)
    I reviewed the work permission checklist and checked the working conditions. I have reviewed the all aspects of the task/activity and am satisfied
    with the arrangements as detailed in the “risk assessment” have been put in place and certify that the activity detailed above is authorized to
    proceed
    Permit Issuer Name: Signature/Date:
    Acknowledge by Contractor's Safety Engineer/Officer
    I have reviewed the work permit, and verified entire checklist corresponding to workplace. All the necessary control measures has been taken
    according to risk assessment and additional precautions are implemented.
    Name : Signature/Date:
    Clearance and cancellation after work or Suspension of permit
    Clearance. (Site Manager)
    All men, materials, tools equipment, housekeeping etc. under my charge have been withdrawn. The permitted work is complete / not complete.
    Name: Signature/Date:
    Suspension
    This permit is suspended, I have notified the Authorized person specified that the work is not complete the area / equipment is not safe to use.
    Name: Signature/Date:
    Contractor LOGO WORK AT HEIGHT PERMIT

    List of additional precaution measures required (SEC Consultant/ Contractor's Safety Engineer/ Officer)

    1.

    2.

    3.

    4.

    5.

    Permit Re-Validation

    Sl. Receiver Contractor's


    Date Time Issuer Signature Remarks
    No Signature Safety Signature

    This permit is valid for 7 days from the date of issue.

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