Elevated Work Permit
Document Control Company: [COMPANY NAME] · Logo: [COMPANY LOGO] · Address: [COMPANY ADDRESS] Prepared by: [RESPONSIBLE PERSON] · Date: [DATE] · Approved by (signature): _________________
| Field | Value |
|---|---|
| Category | Fall Protection |
| Recommended Industry | All |
| Document Type | Permit |
| Access Level | Starter |
| Last Reviewed | 2026-06-29 |
| Last Updated | 2026-06-29 |
How to Use This Template
Complete and authorize this permit before the work begins. Verify the controls are in place, obtain the required approvals, and post or retain the permit for the duration of the work.
Permit
Complete and authorize before elevated work where required by your program.
| Field | Entry |
|---|---|
| Permit #: | [____] |
| Location / task: | [____] |
| Height / exposure: | [____] |
| Fall protection system used: | [____] |
| Anchor points identified/rated: | [____] |
| Equipment inspected: | ☐ Yes |
| Rescue plan in place: | ☐ Yes |
| Weather suitable: | ☐ Yes |
| Authorized by (competent person): | [NAME / SIGNATURE] |
| Date / time issued: | [____] |
| Expiration: | [____] |