Doc No.

Your Company Logo FORM Rev. A

Page 1 of 1

WORKING AT HEIGHT

Location: Client: Project No.:

Date: Time: Evaluator:

No. ITEMS
1 Equipment beneath are protected to avoid damage by falling objects Yes No N/A
2 Safe and proper platforms are provided as working places Yes No N/A
3 Guardrails of adequate strength are provided/erected at platforms Yes No N/A
4 Safety precautions have been taken to prevent workers and objects from falling Yes No N/A
down
5 Workers are using the right personal protective equipment (PPE) Yes No N/A
6 Workers are using and tying off safety harness when working at height Yes No N/A
7 Ladders are provided for safe access and are secured at the top Yes No N/A
8 Workers working at height are inducted Yes No N/A
9 Tool-Box-Meetings are conducted for the workers working at height Yes No N/A
10 Falling sparks are controlled by using a fire blanket Yes No N/A
11 Mandatory signs are erected beneath elevated works Yes No N/A
12 The area below is barricaded to prevent unauthorized entry Yes No N/A
13 If lifelines are used, they are inspected daily and inspection is recorded Yes No N/A
14 It is not allowed to work on elevated areas during thunderstorm/rain
15 A work permit is required for working at height Yes No N/A

Remarks: