• Audit Title

  • Site Name

  • Conducted on

  • Auditor

  • Location
  • Site EHS Manager

  • This Annual Program Review covers the overall Permit to Work process and Non-Routine Activities. It does not include the Hazardous Energy Control (LOTO), Confined Space, Work at Heights or Hot Work programs. These programs are detailed in separate Annual Program Reviews.

Applicable Standards

  • Select those standards that apply.

Documents Reviewed

  • Written Program

  • Medical Surveillance

  • Training Program

  • Training Records

  • Accident or Near Miss Investigations

  • Completed Permits

  • Take 5 Cards

  • Permit to Work Audits and or Metrics

  • Site specific documents (list any site specific documents reviewed as part of APR)

Program Execution

  • Is there an IOSS program leader on site?

  • Is the site using the J&J standardized permits?

  • Is there a permit Authorization matrix for the site? (A listing of who can approve specific permits)

  • Is the Permit Authorization Matrix current? (meaning the names on the matrix are all still in place)

  • How many people are involved with authoring permits?

  • Does the IOSS Program Leader, EHS or Facilities, review and provide feedback on permits in some manner?


  • What is the frequency of training?

  • Does the training program cover the required program elements?

  • Describe the training program.

Medical Evaluation

  • Is the list of participants in the medical surveillance program for Physical Hazards aligned with the list of employees who perform live electrical work or work at heights?

  • What is the system for identifying and notifying those who are required to be in the medical surveillance program?

Employee Discussions

  • Discussions were held with the following groups or employees on site. List number of people when applicable.

Plant Tour

  • Is there a central location(s) with blank permits?

  • Is there a central location for completed permits to be returned?

  • Were any Permit to Work or Non-Routine activities observed during the site tour?

  • Were the appropriate permits, Take 5 or risk assessments in place?

  • Were the appropriate permits, Take 5 or risk assessments completed accurately?

  • Had the content of the permits, Take 5 or risk assessments been reviewed with those completing the task?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.