Permit to Work – Roof Access

SECTION 1 - TO BE COMPLETED BY THE PERSON AUTHORISING THE PERMIT

Department/Faculty/Company requesting access:

________________________________________________

Name of Person/s requiring access:

_______________________________________________________

Employee  Student  Contractor  Visitor 

Location of proposed work

Location:
____________________________________________________________________________________

Purpose of Access: ____________________________________________________________________________

_________________________________________________________________________________________________
_

_________________________________________________________________________________________________
_

Completion Details

Permit Valid (date): ______________ from _____________ am/pm to: _____________ am/pm

Supervising Person:
______________________________________________________________________________

Job Title: ___________________________________________________________________________________

a) Risk assessment has been carried out & is attached  Yes  No

b) Method statement has been produced & is attached  Yes  No

c) Additional emergency evacuation procedures are in

place if required  Yes  No

SECTION 2 - TO BE COMPLETED BY THE PERSON ACCESSING THE AREA

I understand and will ensure compliance with Risk Assessment and Method Statement

Print Name: _____________________________________________________

Signature: _____________________________________________________ Date:

___________________

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SECTION 3 - AUTHORISATION BY ESTATES

I believe the operation can be completed safely. The above request has been authorised as
part of the on-going activities relevant to the responsibilities of the College.

Estates Manager/Health and Safety Officer:

_______________________________________________________

Date: ____________________

To be signed on completion of work

Estates Manager/Health and Safety Officer:

_______________________________________________________

Date: ___________________