Working at Heights Permit Template
Template for Working at Heights Permit. Customize this template for your specific needs.
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Document: Working at Heights Permit
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Version 1 • Last updated 7/27/2026
WORKING AT HEIGHTS PERMIT
Permit Number: [PERMIT-NUMBER] Date of Issue: [DATE-ISSUE] Time of Issue: [TIME-ISSUE] Valid Until: [DATE-EXPIRY] Time Valid Until: [TIME-EXPIRY]
COMPANY DETAILS
Company Name: [COMPANY-NAME] ABN: [ABN] Site Address: [SITE-ADDRESS]
WORK DETAILS
Task Description: [TASK-DESCRIPTION] Location of Work: [SPECIFIC-LOCATION]
HEIGHT ASSESSMENT
Height at which work will be performed: [HEIGHT-METRES] metres Type of structure: [STRUCTURE-TYPE]
HAZARD IDENTIFICATION
Identify all hazards present at the worksite:
- Fragile roof surfaces
- Unguarded edges
- Falls through openings
- Falling objects
- Weather conditions (wind/rain)
- Overhead powerlines
- Uneven ground for equipment
- Other: [OTHER-HAZARDS]
RISK CONTROL MEASURES (HIERARCHY OF CONTROLS)
Level 1: Elimination
- Can the work be done on the ground? (Yes/No)
- Details: [ELIMINATION-DETAILS]
Level 2: Engineering Controls
- Guard rails installed
- Scaffolding erected (Tag Number: [TAG-NUMBER])
- Elevated Work Platform (EWP) used
- Safety mesh installed
- Details: [ENGINEERING-DETAILS]
Level 3: Administrative Controls
- Warning signs erected
- Exclusion zones established
- Permit system in use
- Details: [ADMIN-DETAILS]
Level 4: PPE
- Safety harness worn
- Lanyards/Inertia reels used
- Hard hat
- Safety boots
- Details: [PPE-DETAILS]
EQUIPMENT CHECK
| Equipment Type | ID Number | Inspection Status | Inspector Initials |
|---|---|---|---|
| Harness | [HARNESS-ID] | [ ] Current | [ ] |
| Lanyard | [LANYARD-ID] | [ ] Current | [ ] |
| EWP | [EWP-ID] | [ ] Current | [ ] |
| Ladder | [LADDER-ID] | [ ] Current | [ ] |
WORKER COMPETENCY
Workers authorised to perform this task:
- Name: [WORKER-1] | Licence/Qualification: [QUAL-1]
- Name: [WORKER-2] | Licence/Qualification: [QUAL-2]
AUTHORIZATION AND SIGN-OFF
I confirm that the above control measures are in place and understood.
Authorised Person: [AUTHORISER-NAME] Position: [POSITION] Signature: [SIGNATURE]
Worker Acknowledgement: I acknowledge I have read and understood the risks and controls listed above.
Worker Name: [WORKER-NAME] Signature: [SIGNATURE]
PERMIT CLOSURE
Work completed at: [TIME-FINISHED] Area left safe and clean: [ ] Yes [ ] No Final inspection by: [INSPECTOR-NAME] Signature: [SIGNATURE] Date: [DATE]
About this Template
Part of the Working at Heights Permit document collection
Document Type
Working at Heights Permit
A formal document authorising specific high-risk work at heights to ensure safety compliance and risk management on site.