Working at Height Certificate

Working location ................................Equipment No..............................Inspector.......................................

PTW No: ......................................... Date: ................................................
Scope of work: ........................................................................................

List of item need to be checked before working Yes No N/A

1. The ground condition is enough stability for working and there is no obstacle to the work
2. Install barricade and warning sign at the working location
3. Scaffolding must meet the BS standards and passed inspection (with the green scaffold-
tag and not more than 7 days)
4. Opening spaces or holes where people can falling down shall be installed cover or hard
barricade.
5. The Ladder shall have safe condition and ready to use, It shall be passed the inspection
and the sticker still valid. (Workplaces that are at risk with electricity must use any type
of non-conductive material, such as fiber or require protection against electric contact
with ladders).
6. In case of working nearby the electric cable, shall install insulation and clarify the safety
distance:
6.1 Safety distance less than 2.4 m from conductive less than 12,000 Volts
6.2 Safety distance less than 3 m from conductive less than 33,000 Volts
6.3 Safety distance less than 3.3 m from conductive less than 69,000 Volts
6.4 Safety distance less than 3.9 m from conductive less than 115,000 Volts
7. Fall protection devices, such as safety harness must be in good condition and ready for
use. These equipment must be passed monthly inspection and applied monthly inspection
sticker
8. The hook is stable and strong enough to support the weight of the work
9. All workers who work at height shall pass the specific training course for working at
height and conduct the health check (blood pressure test, alcohol test, temperature test)
10. Material that are brought up to the height must be protected from falling such as binding
object, or install safety net
11. No rain, wind, storm or other environment issue that can affect to the work
In case of emergency/incident case:
Emergency contact mobile no………………………

Name………………. Signature……….. Sub-contractor HSE Supervisor Date: ……………Time…………

Name………………. Signature…………….. EPC HSE Supervisor Date: ……………Time……………

Note : 1. When all or any items of checklist is “No”, not allow to work at height
2. Working at Height Certificate shall be attached with PTW and available at site.
3. In case found that “No” during working, the work shall be stopped and corrective action until finish, fill the
detail in PTW and re-approve permit.