Form No.

QHSE-ST100
METITO (OVERSEAS) QATAR W.L.L.
Revision
2
Date
09.03.2021
Permit To Work - Work At Height
Page
2

Part 1 GENERAL INFORMATION ( to be filled by the Permit Raiser )

Permit Number Date
Name and position of the executor of the job ( Precise name of COMPANY IF SUBCONTRACTOR ) :

Contractor Phone No :
Work location : Related PTW No : Date & Time Start :

Date & Time End :

Work description :

Part 2 PRECAUTIONS TO BE TAKEN

Note: The following section of this permit must be completed and signed by the Permit Authorizer before work is to proceed and only work
listed above may be completed.
Does the following equipment to be used during the works are in good working condition and is fit for use:
Elevated work platform Roof and/or ladder anchor
(i.e. scissor lift….) ☐Yes ☐No NA points
☐Yes ☐No NA
Step ladder ☐Yes ☐No NA Extension ladder ☐Yes ☐No NA
Mobile scaffold ☐Yes ☐No NA Appropriate footwear ☐Yes ☐No NA
Ropes and harness ☐Yes ☐No NA Edge protection ☐Yes ☐No NA
Scaffold ☐Yes ☐No NA Safety net ☐Yes ☐No NA
Other:
Emergency precautions to be taken - in the event of an incident

Does the following Safety equipment and PPE to be used have current inspection tags and is it in good condition?
Fall arrest ☐Yes ☐No ☐ NA Travel restraint system ☐Yes ☐No ☐ NA
Safety net ☐Yes ☐No ☐ NA Harness ☐Yes ☐No ☐ NA
Personal energy absorber ☐Yes ☐No ☐ NA Standard PPE ☐Yes ☐No ☐ NA
Lanyards ☐Yes ☐No ☐ NA Karabiners ☐Yes ☐No ☐ NA
Anchor points ☐Yes ☐No ☐ NA Access equipments ☐Yes ☐No ☐ NA
Other:
The following control measures have been implemented for the duration of the works:
Barricades ☐Yes ☐No ☐ NA Signage ☐Yes ☐No ☐ NA
spotter ☐Yes ☐No ☐ NA Training of concerned workers ☐Yes ☐No ☐ NA
Rescue plan prepared ☐Yes ☐No ☐ NA Required PPE issued ☐Yes ☐No ☐ NA
Personnel medically Rescue equipment and person
☐Yes ☐No ☐ NA ☐Yes ☐No ☐ NA
capable to Work at Height available on site
Access / egress identified ☐Yes ☐No ☐ NA Other:

The following environmental factors have been assessed and are suitable for the works:
Weather ( high winds, Stored material / vegetation
slippery surfaces ,ect..)
☐Yes ☐No ☐Yes ☐No
Other:
The permit is immediately void if any items in the above section is checked “NO.”
Does the activity require the entry to a Confined Space? If yes, complete a Confined Space Permit.
☐Yes ☐No
Does the activity require the removal of grid mesh flooring or handrails? If yes , ensure removal
☐Yes ☐No
precautions are planned
Permit Authorizer to fill the above section - Name & Signature : HSE Assigned Person to review the compliance of above section : Name
& Signature :
 Part 3 CHECK ON-SITE AND AUTHORIZE THE Work at Height
To be filled in by Permit Authorizer after check on-site
I confirm that all control measures are implemented and all workers understand the requirements of this
permit
☐Yes ☐No
I authorize the work at height to start
☐Yes ☐No
Date &
Name /position Signature
time

To be filled in by Permit Raiser

I acknowledge the receipt of this Work at Height Permit and understand its requirements. I confirm that the requirements of this document will
be fully briefed to all employees carrying out the work
Date &
Name /position Signature
time

Part 4 CLOSURE OF THE PERMIT

Work site have been inspected - The work is complete , all equipment returned and the site is safe .
To be signed by Permit Raiser : To be signed by Permit Authorizer:
Date and Time: Date and Time:

Signature: Signature:

Part 5 CANCELATION (IF REQUIRED)

REASONS :

No further work is permitted. A new permit must be issued prior to continuation of any further work

Name /position Signature Date & time