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Project Information
Project Name
Site Address
Contractor
Supervisor Name
Work Details
Description of Work
Start Date
Estimated Duration
Maximum Work Height
Risk Assessment
Have all hazards been identified?
Have control measures been implemented?
Have workers been briefed on the risks?
Safe System of Work
Access Equipment to be Used
Fall Protection Equipment to be Used
Exclusion Zones Established
Permit to Work Completed
Emergency Procedures in Place
Competence and Training
Workers Trained in Working at Height
Supervisor Competent in Working at Height
Equipment Inspected and Fit for Purpose
Sign Off
Prepared by (Name)
Prepared by (Signature)
Date
Approved by (Name)
Approved by (Signature)
Date