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Run: Working at Heights Permit

A Working at Heights Permit template for authorizing elevated work, checking fall protection, and confirming rescue arrangements before the job starts.

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Permit Overview

Permit title (required)

Work order or job number

Optional reference for internal tracking and audit trail.

Site / area where work will be performed (required)

Description of work at height (required)

Planned work date (required)

Planned start time (required)

Planned end time (required)

Work at Height Details

Estimated work height above ground or lower level (feet) (required)

Does this work exceed the applicable OSHA fall protection threshold? (required)

Primary access method (required)

If other, specify access method

Work area condition (required)

Fall Protection and Equipment

Fall protection system to be used (required)

Has all fall protection equipment been inspected before use? (required)

Describe any damaged, missing, or out-of-service equipment

Have anchor points been verified for strength, compatibility, and location? (required)

Anchor point details

Include anchor location, attachment method, and any engineered or approved anchorage information.

Hazards and Controls

Known hazards at the work location (required)

Other hazards

Control measures to prevent falls or dropped objects (required)

Are weather and surface conditions acceptable for the planned work? (required)

Weather or surface condition notes

Rescue and Emergency Plan

Is a rescue plan in place for a fall event? (required)

Primary rescue method

If other, specify rescue method

Are trained rescuers and required equipment available on site?

Emergency contact number (required)

Use the site emergency number or control room contact.

Authorization and Acknowledgment

Permit requestor name (required)

Enter the name of the person requesting the permit.

Requestor role (required)

Approving supervisor name (required)

Permit approval status (required)

Approval conditions or restrictions

I confirm the information provided is accurate and work will not begin until all controls are in place. (required)

Yes No N/A

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