Working at Height Permit
1. Work Details
Company
*
Name of person completing permit
*
First Name
Last Name
Email
example@example.com
Date of works
*
-
Day
-
Month
Year
Date
Emergency Phone Number
*
Please enter a valid phone number.
Format: (00) 0000-0000.
Name of ALL person/s conducting work
*
Site
*
Please Select
Brendale Paint and Panel
Brendale Pre-Delivery
Brendale Toyota
Brendale Used Reconditioning
Coopers Plains Hino
Eagle Farm Hino
Fortitude Valley Lexus
Indooroopilly Lexus
Indooroopilly Toyota Used
Kedron Head Office (59 Kitchener Road)
Kedron Toyota New
Kedron Toyota Used
Maroochydore Lexus
Nerang Hino
Southport Lexus
Springwood Lexus
Taringa Toyota
Location of work (i.e Service Area)
*
Description of work
*
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Hazards and Risk Controls
Temporary Ladders (Extension or Step)
Will ladders be used?
*
Yes
No
Is the ladder rated for industrial use?
*
Yes
No
Is the ladder manufactured to Australian Standards?
*
Yes
No
Is the ladder in good working condition (e.g. rungs, steps, rails, etc.)
*
Yes
No
If persons and/or vehicles are in close proximity, are controls in place? If 'yes', note details in JSA / RA
*
Yes
No
N/A
Is the ladder secured during use? If 'no' note alternative control measures in JSA / RA (e.g. person holding ladder)
*
Yes
No
Further comments?
*
Yes
No
Comments
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Hazards and Risk Controls
Scaffold
Will scaffolding be used?
*
Yes
No
Have all persons completing works (including supervisor) completed working at heights training?
*
Yes
No
Has gradient, height access and load been considered for the type of scaffolding to be used?
*
Yes
No
Confirm that the person erecting the scaffolding is qualified if scaffold is over 4 metres in height
*
Yes
No
N/A
Have operator's ladders and guard rails been erected to prevent fall?
*
Yes
No
If persons and/or vehicles are in close proximity, are controls in place? If 'yes' note details in JSA / RA
*
Yes
No
N/A
Further comments?
*
Yes
No
Comments
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Hazards and Risk Controls
Elevated Work Platform (EWP)
Will an Elevated Work Platform (EWP) be used?
*
Yes
No
Have all persons completing works (including supervisor) completed working at heights training?
*
Yes
No
Has gradient, height, access and load been considered for the type of EWP if a licence is required for the unit in use?
*
Yes
No
N/A
Are qualified person's only operating EWP if a licence is required for the unit in use?
*
Yes
No
N/A
Confirmation that the EWP is within current certification for use?
*
Yes
No
Will fall arrest full body harness be worn and connected to prevent fall?
*
Yes
No
Confirm that there are no overhead power lines prior to commencing works. If 'yes' cease work until compliance with the legislative requirements for working around power lines has been met
*
Yes
No
If persons and/or vehicles are in close proximity, are controls in place? If 'yes' note details in JSA / RA
*
Yes
No
Further comments?
*
Yes
No
Comments
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Hazards and Risk Controls
Working on the Roof
Will you be working on a roof?
*
Yes
No
Have all persons completing works (including supervisor) completed working at heights training?
*
Yes
No
Are work positioning or fall arrest systems in place where the roof is steeply pitched (>1 in 6 or 15 degrees)?
*
Yes
No
N/A
Are walkways, platforms or boards in place for work in fragile roof coverings (including working within rood spaces over ceilings)?
*
Yes
No
Are voids, gutters or skylights in or near work area, controls in place? If 'yes' note details in JSA / RA
*
Yes
No
Are work positioning or fall arrest systems in place where work will be within two (2) metres of the edge with required attachment point?
*
Yes
No
N/A
Are barriers or guardrails in place where work will be within two (2) metres of the edge?
*
Yes
No
N/A
If persons and/or vehicles are in close proximity, are controls in place? If 'yes' note details in JSA / RA
*
Yes
No
N/A
Are lanyards or other measures in place to prevent tools and equipment falling from height?
*
Yes
No
Has the area beneath / around the work area been cordoned off and signposted?
*
Yes
No
Are fall arrest and work positioning systems compliant to Australian Standards, have current tagging and in safe working condition?
*
Yes
No
Are there radio frequency hazards in / near the work area, controls in place? If 'yes' note details in JSA / RA
*
Yes
No
Is another person going to be working in sight of persons using fall arrest equipment? If 'no' allocate a person to stand-by
*
Yes
No
Do weather conditions (such as strong winds, rain, heat, glare, or electrical storms) present a hazard? If 'yes' note details in JSA / RA
*
Yes
No
Further comments?
*
Yes
No
Comments
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Hazards and Controls
General
Has the contractor completed group induction and will at all times comply with the safety requirements?
*
Yes
No
Have all relevant persons received instruction in the RA or JSA for the activity?
*
Yes
No
Have the weather conditions been assessed and verified as safe?
*
Yes
No
Is there any special or additional PPE required (eyes, face, feet, legs)? If 'yes' note in comments what was supplied and initial once all relevant persons have been issued PPE
*
Yes
No
Any other permits required (council, hot work, etc.)? If 'yes' note details and also confirm these have been obtained in JSA / RA
*
Yes
No
Is there any known medical condition that may affect the person to perform work at heights? E.g. vertigo / epilepsy? If 'yes' ensure person is medically certified to complete works
*
Yes
No
Additional risk controls required? If 'yes' note details in comments section and also note on JSA / RA once in place
*
Yes
No
Further comments?
*
Yes
No
Comments
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Post Fall Recovery Plan
What method will be used to recover person/s if a fall event occurs? (E.g. ladder, EWP)
Are all persons involved with the work aware of the plan? If 'no' ensure this has been administered prior to commencing works
*
Yes
No
Is there two way communication for the job, unless work is in clear sight of another person not working at height (spotter)? If 'no' organise communications prior to commencing work
*
Yes
No
N/A
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Acceptance and Authority
All persons conducting work at heights understand the intentions and agreed measures of this permit.
*
All understand and agree
Submit
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