Working at Height Checklist Form
Complete this checklist to ensure safety readiness before starting any work at height.
Worker Full Name
*
First Name
Last Name
Date of Checklist
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Checklist
*
Hour Minutes
AM
PM
AM/PM Option
Job/Work Location
*
Equipment Inspected (select all that apply)
*
Harness
Lanyard
Anchor Points
Lifeline
Helmet
Other
Access Method
*
Ladder
Scaffold
Mobile Elevated Work Platform (MEWP)
Rope Access
Other
Weather/Environmental Conditions
*
Clear
Windy
Rainy
Hot
Cold
Other
Hazard Checks (select all that apply)
*
Overhead hazards checked
Fragile surfaces identified
Falling object risk controlled
Electrical hazards managed
Access/egress clear
Other
Fall Protection in Place?
*
Yes
No
Not Applicable
Rescue Plan and Equipment Ready?
*
Yes
No
Permit/Authorization Status
*
Permit issued and valid
Permit not required
Permit expired or missing
Incident Observations or Notes
Final Sign-Off (Responsible Person's Name)
*
Submit Checklist
Should be Empty: