WORK AT HEIGHT PERMIT Form # HSEQ - WHP Rev.docx

1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company

2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:



Detail of Surroundings:



Permit Validity:
Time (from): __________Hrs.
Time (To): __________Hrs.
Date:

Type :
Work at height without guardrails

Work at height on fragile surfaces


3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐

Area barricaded & proper signage are posted? ☐ ☐ ☐

Qualified and briefed workers? ☐ ☐ ☐

PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐

Tools/Equipment inspected? ☐ ☐ ☐

Safe means of access/ Egress? ☐ ☐ ☐

Lifeline available and inspected? ☐ ☐ ☐

Fragile surface covered / work surface protected? ☐ ☐ ☐

Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐

Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐

Harness anchorage point checked? ☐ ☐ ☐

Load bearing capacity of anchoring point checked? ☐ ☐ ☐

Load bearing capacity of fragile service checked? ☐ ☐ ☐

Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐

Others ( Specify) ☐ ☐ ☐




4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity

Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):




5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:

6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.

Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.

Evaluator Signature : Time:

1. WORK AT HEIGHT PERMIT

Page 1 of 2 Form # HSEQ-WHP (Rev 2 - Mar 23)



1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting
Contractor/Company


2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:




Detail of
Surroundings:




Permit Validity:

Time (from): __________Hrs.

Time (To): __________Hrs.

Date:

Type :

Work at height without guardrails

Work at height on fragile surfaces


3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Yes-No-NA
Method Statement and Risk Assessment developed, approved and communicated? ☐ ☐ ☐
Area barricaded & proper signage are posted? ☐ ☐ ☐
Qualified and briefed workers? ☐ ☐ ☐
PPE of workers available & inspected as per MS/RA? ☐ ☐ ☐
Tools/Equipment inspected? ☐ ☐ ☐
Safe means of access/ Egress? ☐ ☐ ☐
Lifeline available and inspected? ☐ ☐ ☐
Fragile surface covered / work surface protected? ☐ ☐ ☐
Dimensions of platform and restrain lanyard match safety requirement? ☐ ☐ ☐
Harness with double lanyard provided and its use briefed to workforce? ☐ ☐ ☐
Harness anchorage point checked? ☐ ☐ ☐
Load bearing capacity of anchoring point checked? ☐ ☐ ☐
Load bearing capacity of fragile service checked? ☐ ☐ ☐
Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐
Others ( Specify) ☐ ☐ ☐

2. WORK AT HEIGHT PERMIT

Page 2 of 2 Form # HSEQ-WHP (Rev 2 - Mar 23)

4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I
consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Date /Time
Comments (if any):




5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:

6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature : Time: