Work at Height Permit Form
Use this form to request authorization for work at height and provide the details needed to review the task, controls, and emergency arrangements.
Applicant and Work Details
Applicant full name
*
First Name
Middle Name
Last Name
Job title / role
*
Company / contractor name
*
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
*
example@example.com
Work location
*
Specific task to be performed at height
*
Planned start date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Planned end date and time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Work at Height Controls and Risk Information
Access method/equipment to be used
*
Ladder
Scaffold
MEWP
Roof access
Other
Fall protection measures planned
*
Harness and lanyard
Guardrails
Safety nets
Work restraint
Fall arrest system
Other
Main hazards identified
*
Falls from height
Falling objects
Fragile surfaces
Slips, trips or uneven footing
Overhead obstructions
Electrical hazards
Other
Weather, ground and access constraints
Rescue and emergency arrangements
*
Supervisor name
*
Permit approver / authorizing officer name
*
Risk controls or additional precautions
*
Attachments and Additional Information
Supporting Documents
*
Upload a File
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Choose a file
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Additional Information
Submit Permit Request
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