Permit for Exiting/Entering Aerial Work Platform
Jobsite
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Date
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Time Issued
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Hour Minutes
AM
PM
AM/PM Option
Expiry Time:
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Hour Minutes
AM
PM
AM/PM Option
AWP OPERATION: Describe in detail the work to be performed and the location/area involved:
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Why can the work not be done by means other than exiting the AWP? (ex. scaffolding, alternate access)
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AWP INFO
1. Make, type, model number:
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2. Describe accessories attached to the boom:
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3. Boom length and type:
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4.Weight or capacity of aerial work platform:
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5. Required operating radius:
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6. Required lift height for AWP specific height:
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7. Pre-use inspection of AWP completed?
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Yes
No
8. AWP operators trained in the use of AWP?
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Yes
No
FALL PROTECTION
1. Are workers wearing approved fall protection equipment that allows for 100% tie-off?
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Yes
No
2.Do workers have fall protection training?
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Yes
No
SITE AND STRUCTURE CONDITIONS
1. Ground condition (level, dry, wet, undisturbed, etc.):
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2. Wind direction and speed (specific speed and direction):
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3. Weight of materials and/or small tools inside manbasket (specific weight):
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4. Does adjacent structure have an approved tie-off point?
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Submitted by:
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Date required
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Approved by: Project Superintendent
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Approved by: Project HSE
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Date
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Approved by: Site Manager
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Date
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Submit
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