Templates
Permit to work at height form

Permit to work at height form

Authorize elevated work activities only after thorough safety verification and risk assessment.

Use this template
or download pdf
Permit to work at height form

Authorize elevated work activities only after thorough safety verification and risk assessment.

Use this template
or download pdf

A permit to work at height form is a critical safety document that’s essential for managing and controlling risks associated with elevated work environments. This template provides an organized approach to assess hazards, verify safety measures, and authorize work only when proper precautions are in place.

The Institution of Occupational Safety and Health (IOSH) reports that fall from height is the second leading cause of injury death around the world, amounting to around 684,000 deaths every year. With this template, you can document thorough pre-work inspections, equipment checks, and emergency procedures. It supports you in meeting regulatory requirements as you protect workers from potentially fatal accidents.

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Preview of the template
Page 1
General Information
Date and Time of Work
Description of Work
Work to be Carried Out By
Risk Assessment
Have the hazards associated with the work been identified?
Have the risks been evaluated and appropriate control measures been put in place?
Is the work area clear of obstructions and hazards?
Have anchor points been identified and assessed as suitable?
Have weather conditions been considered?
Equipment and PPE
Have the appropriate fall protection equipment been provided?
Has the equipment been inspected and found to be in good working order?
Have operatives been trained in the use of the equipment?
Is the necessary PPE available and being used?
Emergency Arrangements
Have emergency procedures been established?
Have emergency contacts been identified?
Is a rescue plan in place?
Have the nearest emergency services been notified?
Authorization
Name of Responsible Person
Signature of Responsible Person
Date
Name of Permit Issuer
Signature of Permit Issuer
Date

Frequently asked questions

When should a permit to work at height be suspended or canceled?

A permit should be immediately suspended if weather conditions deteriorate, safety equipment becomes damaged, new hazards emerge, work scope changes, incidents occur, required personnel leave the site, or emergency situations arise. The permit issuer or safety supervisor has authority to cancel permits when safety cannot be guaranteed.

What training should workers have before being included on a work at height permit?

Workers need training on height safety regulations and proper use of fall protection equipment. They should know how to recognize hazards and respond to emergencies. Understanding of the permit system itself is important, as is knowing proper communication protocols. Most sites require annual refresher training, and you should verify these records during the permit approval process.

How does the handback process work for a permit to work at height?

When work is finished, the permit recipient needs to check that the area is safe. They should ensure all tools and equipment are removed and any necessary barriers remain in place. Any issues encountered should be documented. The recipient then signs the handback section, and the issuer makes a final inspection before formally closing the permit.

How do you properly complete the risk assessment in the permit form?

First, identify hazards specific to your height work situation. Evaluate how likely each risk is and how severe the consequences could be. You’ll also need to document what controls you already have in place. Determine if you need additional safeguards and verify everything is implemented correctly. Finally, make sure the remaining risk level is acceptable before signing off.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.