Working at Heights Permit TX Whiskey

What

How

Where

The task has been reviewed and it is not possible to eliminate WAH?

• Yes
• No
• N / A

Choose all that apply

• Travel Restraint, Falls are prevented- PPE Limits Travel

• Fall Arrest, does not prevent fall- Limits Fall

• Articulating boom lift- Fall restraint system required at all times

• Scaffolding (stationary) Must have valid tag, must be designed

• Scaffolding (portable/rolling) Fall protection with safe access

• Scissor Lift- (requires 100% tie off) may need two lanyards on for basket and one for exit

• Work Positioning System, continuous tension. restrained by PPE

• Guardrail System (passive fall protection)

• Other

If outside - is weather suitable?

• Yes
• No
• N / A

Is work surface level?

• Yes
• No
• N / A

Work beneath is controlled?

• Yes
• No
• N / A

Overhead power lines Present?

• Yes
• No
• N / A

Choose all that apply

• Fixed anchor point

• Fixed ladder grab

• Mobile anchor point (Lift, I-Beam runner, anchor strap, roof carts etc.)

• Restraint lanyard

• Retractable lanyard

• Shock absorbing lanyard ( not to be used less that 20ft from lower level)

• Work Positioning system

• 100% Tie off (exiting a lift, roof access, etc.)

• Physical control in place for restricted access zone (overhead work)

• Other

Fall distance calculation has been determined?

• Yes
• No
• N / A

Rescue plan has been completed?

• Yes
• No
• N / A

Are there skylights present? – if yes must be guarded to prevent fall through

• Yes
• No
• N / A

Do you have a communications Plan?

• Yes
• No
• N / A

Are you working within 6' of the roofs edge?

• Yes
• No
• N / A

Is temporary roof guard needed and in place?

• Yes
• No
• N / A

QUALIFIED PERMIT APPROVER SIGNATURE

TIME ISSUED

TIME EXPIRES

PERMIT RECEIVER SIGNATURE

TIME ISSUED

TIME EXPIRES

Name of person performing WAH

Valid training documentation