Location of the Work: .............................................................................................................

Type of work to be executed : ..............................................................................................Date: …………………

Section A: General Requirements

Sl.
DESCRIPTION YES NO REMARKS
No.
Every open side or opening into or through which a person may fall is
1
covered or guarded by an effective barrier to prevent falls.
Where covers are used for openings, are these covers securely fixed to
2
prevent accidental displacement?
Where any work at height is to be carried out, is safe means of access to
3
and egress provided?
Where a ladder is used for access or as a working place, are adequate
handholds provided to a height of at least one metre above the place of
4 
landing of the highest rung to be reached by the feet of any person on
the ladder?

5 Are the hazards and risk control measures communicated to all workers?
Have all workers received the necessary instruction, information and
6
training for them to perform work at heights?
Is there adequate supervision to ensure that safe work practices for
7
working at heights are in place?

8 Is sufficient and secured anchorage provided?

Is the anchorage point or lifeline being used by the workers who are
9
working at height?
Are workers instructed on the proper method to wear and use the safety
10 harness or restraint belt, as well as attach it to the lifeline or anchorage
point?

Section B : Formwork
Is form work timber beam extension planned for the installation of safety
11
post in regular interval?

1
 Is adequate form work workspace (Minimum 1m) extension planned from
12
the slab edges?

13 Is the form work free from voids to avoid fall from height?

14 Form work extensions are uniform and adequate supports are provided.
Are persons involved in formwork (i.e. formwork supervisor, formwork
15
workers) adequately trained?
Where openings are present on the formwork structure, is the opening
16
adequately covered or guarded to prevent falls?

Any other precautions taken:

I have taken all the above precautions and the operatives are briefed about the work procedure.
Name: ………………………………....…. ( Engineer /Supervisor) Signature: ……………………….
Date: …………………… Time: …………………………….

Work shall be carried out (only) after complying with the precautions listed above.
Name: …………………….......................... (PM/CM / HSE Rep.) Signature: ……..…………………........
Date: ……………………. Time: ……………………..........………

The work has been carried out safely and the area has been cleared.

Name: …………………................……… (PM/CM / HSE Rep.) Signature: ………………….......…….

Date: ……………………. Time: ……………………........………