QA/QC  › HSE Permits & Safety  › Work at Height
Form · QC-HSE-PRM-001
Work at Height Permit
22 checkpoints across 7 sections. Before any work above 1.8 m commences; revalidated daily or per shift
22 Checkpoints
7 Sections
Per shift or per work activity at height
HSE Officer, Permit Issuer

Checklist Preview

S.No.CheckpointIS RequirementStatus
A. WORKER QUALIFICATION AND FITNESS
A1All workers verified medically fit for work at height (no vertigo, heart issues, epilepsy, BP issues)
Acceptance: Valid fitness certificate on file; not older than 12 months; signed by registered physician
Cl. 4.2 — Fitness for height work
OK
NC
NA
HOLD
A2Workers have completed height-work safety training and toolbox talk for this activity
Acceptance: Training records verified; TBT attendance signed; refresher within last 6 months
Cl. 5 — Competency
OK
NC
NA
HOLD
A3No worker under 18 or over 60 engaged in height work; not under influence of alcohol/medication
Acceptance: Age documents verified; sobriety confirmed; no medication affecting balance
BOCW Act Sec. 38 — Worker eligibility
OK
NC
NA
HOLD
B. PERSONAL FALL ARREST SYSTEM (PFAS)
B1Full body harness provided to each worker; inspected and tagged within last 3 months
Acceptance: Harness complies with IS 3521; inspection tag valid; no cuts/burns/abrasions on webbing
Cl. 4.3 — Fall protection equipment
OK
NC
NA
HOLD
B2Double lanyard with energy absorber (shock absorber) provided for 100% tie-off
Acceptance: Double lanyard present; shock absorber intact; locking snap-hooks functional
Cl. 4.3 — 100% tie-off
OK
NC
NA
HOLD
B3Anchor points identified, rated >15 kN, independent of work platform/scaffold
Acceptance: Anchor engineered/approved; certified >15 kN; above shoulder wherever possible
Cl. 4.3 — Anchorage
OK
NC
NA
HOLD
B4Fall clearance calculated; sufficient distance below worker to prevent ground contact
Acceptance: Minimum 6 m clearance where lanyard used; shorter with SRL; calculation documented
Cl. 4.3 — Fall clearance
OK
NC
NA
HOLD
C. SCAFFOLD / WORK PLATFORM
C1Scaffold erected by certified scaffolders; tagged GREEN (safe) by competent person
Acceptance: Scaf-tag current (<7 days); inspector's name and sign on tag; no RED/YELLOW tags
Cl. 6 — Scaffold erection
OK
NC
NA
HOLD
C2Guardrails (top-rail 1.0 m, mid-rail, toe-board 150 mm) on all open sides of platform
Acceptance: Top rail 950-1100 mm; mid rail present; toe-board ≥150 mm; no gaps >470 mm
Cl. 6.4 — Edge protection
OK
NC
NA
HOLD
C3Platform fully planked, planks secured, no gaps >25 mm, load rating suitable
Acceptance: Steel planks preferred; overlap ≥150 mm; tied; rated for intended load + workers + tools
Cl. 6.3 — Working platform
OK
NC
NA
HOLD
C4Safe access provided: ladder at correct 4:1 angle, extends 1 m above landing, secured
Acceptance: Ladder tied at top; non-slip base; extends 1 m above; no paint obscuring defects
Cl. 7 — Ladder safety
OK
NC
NA
HOLD
Showing 11 of 22 checkpoints ·
A. WORKER QUALIFICATION AND FITNESS
A1All workers verified medically fit for work at height (no vertigo, heart issues, epilepsy, BP issues)
Cl. 4.2 — Fitness for height work (IS 14489)
Valid fitness certificate on file; not older than 12 months; signed by registered physician
OKNCNAHOLD
A2Workers have completed height-work safety training and toolbox talk for this activity
Cl. 5 — Competency (IS 14489)
Training records verified; TBT attendance signed; refresher within last 6 months
OKNCNAHOLD
A3No worker under 18 or over 60 engaged in height work; not under influence of alcohol/medication
BOCW Act Sec. 38 — Worker eligibility (IS 14489)
Age documents verified; sobriety confirmed; no medication affecting balance
OKNCNAHOLD
B. PERSONAL FALL ARREST SYSTEM (PFAS)
B1Full body harness provided to each worker; inspected and tagged within last 3 months
Cl. 4.3 — Fall protection equipment (IS 3696)
Harness complies with IS 3521; inspection tag valid; no cuts/burns/abrasions on webbing
OKNCNAHOLD
B2Double lanyard with energy absorber (shock absorber) provided for 100% tie-off
Cl. 4.3 — 100% tie-off (IS 3696)
Double lanyard present; shock absorber intact; locking snap-hooks functional
OKNCNAHOLD
B3Anchor points identified, rated >15 kN, independent of work platform/scaffold
Cl. 4.3 — Anchorage (IS 3696)
Anchor engineered/approved; certified >15 kN; above shoulder wherever possible
OKNCNAHOLD
B4Fall clearance calculated; sufficient distance below worker to prevent ground contact
Cl. 4.3 — Fall clearance (IS 3696)
Minimum 6 m clearance where lanyard used; shorter with SRL; calculation documented
OKNCNAHOLD
C. SCAFFOLD / WORK PLATFORM
C1Scaffold erected by certified scaffolders; tagged GREEN (safe) by competent person
Cl. 6 — Scaffold erection (IS 3696)
Scaf-tag current (<7 days); inspector's name and sign on tag; no RED/YELLOW tags
OKNCNAHOLD
C2Guardrails (top-rail 1.0 m, mid-rail, toe-board 150 mm) on all open sides of platform
Cl. 6.4 — Edge protection (IS 3696)
Top rail 950-1100 mm; mid rail present; toe-board ≥150 mm; no gaps >470 mm
OKNCNAHOLD
C3Platform fully planked, planks secured, no gaps >25 mm, load rating suitable
Cl. 6.3 — Working platform (IS 3696)
Steel planks preferred; overlap ≥150 mm; tied; rated for intended load + workers + tools
OKNCNAHOLD
C4Safe access provided: ladder at correct 4:1 angle, extends 1 m above landing, secured
Cl. 7 — Ladder safety (IS 3696)
Ladder tied at top; non-slip base; extends 1 m above; no paint obscuring defects
OKNCNAHOLD
Showing 11 of 22 ·
Inspection Sign-Off
APPROVED
APPROVED WITH CONDITIONS
REJECTED — NCR RAISED
Remarks
Name / Sign / Date
Inspected By
Name / Sign / Date
Reviewed By
Name / Sign / Date