📍 When to use this template
- Before any activity where a worker could fall from a height of 2 meters or more, such as scaffolding, formwork, structural steel erection, or roof work.
- A new permit is required daily before each shift, for each specific location, or if work conditions change.
- Filled by the Contractor's Site Supervisor, verified by the Safety Officer, and approved by the PMC/Client's Engineer before work starts.
Sections & fields
Preview of the template structure. Download Excel to fill on site.
1Header / Project Information7 fields
Project Name
_____________
Contract Package No.
_____________
Shift Timings
_____________
Permit Validity (From/To)
_____________
Prepared By (Contractor)
_____________
2Work Details6 fields
Exact Location of Work (Building/Grid/Axis/Floor)
_____________
Description of Work to be Performed
_____________
Maximum Height of Work (in meters)
_____________
Number of Workers Involved
_____________
Name of Supervisor in Charge
_____________
Tools & Equipment to be Used
_____________
3Fall Protection Checklist (Personal Protective Equipment - PPE)5 fields
Full Body Harness (IS 3521) for all workers? (Y/N/NA)
_____________
Double Lanyard with Shock Absorber provided? (Y/N/NA)
_____________
Safety Helmet with Chin Strap (IS 2925) provided? (Y/N/NA)
_____________
Safety Shoes with good grip provided? (Y/N/NA)
_____________
Condition of all PPE checked before issue? (Y/N/NA)
_____________
4Access, Platform & Scaffolding Checklist6 fields
Scaffolding inspected and tagged 'Safe for Use' (Green Tag)? (Y/N/NA)
_____________
Scaffolding stability, sole plates, and base jacks checked? (Y/N/NA)
_____________
Guardrails (Top rail, Mid rail) and Toeboards in place? (Y/N/NA)
_____________
Safe access/egress provided (staircase/ladder)? (Y/N/NA)
_____________
Working platform fully boarded and free from trip hazards? (Y/N/NA)
_____________
Mobile scaffold wheels locked and outriggers deployed? (Y/N/NA)
_____________
5Anchorage & Lifeline Checklist4 fields
Anchorage points identified and strength verified (>23kN)? (Y/N/NA)
_____________
Horizontal/Vertical lifeline installed and tensioned correctly? (Y/N/NA)
_____________
Lifeline protected from sharp edges? (Y/N/NA)
_____________
Workers trained on proper anchoring and hook-up? (Y/N/NA)
_____________
6General Safety & Emergency Measures6 fields
Area below barricaded and 'Work Overhead' warning signs posted?
_____________
Tool lanyards/tethers used for hand tools?
_____________
Weather conditions checked (High Wind/Rain)?
_____________
Rescue plan in place and communicated to the work crew?
_____________
First aid kit and trained first-aider available nearby?
_____________
Emergency contact numbers displayed?
_____________
7Authorization & Closure6 fields
Permit Issuer (Contractor Supervisor) Name & Signature
_____________
Permit Receiver (Work Crew Leader) Name & Signature
_____________
Safety Officer Verification (Name & Signature)
_____________
PMC/Client Approval (Name & Signature)
_____________
Permit Closure Time
_____________
Area Cleared & Left Safe (Signature)
_____________
💡 Sample filled excerpt
Location: Tower B, 14th Floor Slab Edge (Grid C-D/5-6) | Work: Edge protection fixing | Height: ~45m | PPE Checklist: Full Body Harness (Y), Double Lanyard (Y), Helmet w/ Chin Strap (Y) | Supervisor: Ramesh Kumar | Approved for 9:00 AM to 1:00 PM shift.
⚖ Compliance notes
- Helps comply with the Building and Other Construction Workers (BOCW) Act, 1996.
- Addresses requirements under BOCW (Central) Rules, 1998, specifically Rule 38 (Height and opening), Rule 46 (Scaffolds), and Rule 53 (Safety belt and nets).
- Ensures adherence to safety practices outlined in IS 3696 (Scaffolds) and IS 3521 (Harnesses).
- A key document checked during internal safety audits, client inspections, and by Directorate of Industrial Safety and Health (DISH) officials.