C3 Permit to Work

• Permit No.

• Location
  Address

• Created on

  Date

• Prepared by

Task / Work Details

• Job details Describe the work to be done

• Tools / Equipment to be used

• Materials / Product to be used

• Area(s) of work

• Is any other work currently being undertaken that may interact, affect, or be affected by this work?

  Yes

  No

• Specify other work

• Is action required to inform, stop, or otherwise make safe?

  Yes

  No

• Specify action required

Personnel Details

• Who is the Responsible Person?

• Is the Responsible Person suitably competent to carry out the work?

  Yes

  No

  N/A

• Will others be involved in the work?

  Yes

  No

• Are all personnel to be involved either:<br>Suitably competent; or<br>Under an appropriate level of supervision

  Yes

  No

  N/A

Hazards & Precautions: General

• Is the area clean, tidy, and free from hazards?

  Yes

  No

  N/A

• Is the work area suitably positioned away from other works <br>OR have other suitable means been implemented to prevent other personnel from exposure to risk?

  Yes

  No

  N/A

• Are all personnel involved suitably briefed to local area risks?

  Yes

  No

  N/A

• Is there a Standard Operating Procedure (SOP) for the task?

  Yes

  No

• Confirm the following:

• Operatives involved in this work are briefed to the SOP

  Yes

  No

  N/A

• The SOP is available to the Operatives for reference

  Yes

  No

  N/A

• The SOP will be followed for this work

  Yes

  No

  N/A

• If there is a deviation from the SOP, state the deviation and reason(s)

• Confirm that a Dynamic Risk Assessment (DRA) has been undertaken

  Yes

  No

  N/A

• Are any specific licenses or qualifications required?<br>[State Details]

  Yes

  No

• Is all required PPE available and in suitable condition?

  Yes

  No

  N/A

Hazards & Precautions: Specific

• The following types of work require specific consideration:

• Does the job involve: HOT WORK

  Yes

  No

Hot Work

• Is the floor and surrounding area clear of combustible materials

  Yes

  No

  N/A

• Is any local equipment / material suitably protected or removed?

  Yes

  No

  N/A

• Is there adequate natural ventilation and / or local extraction?

  Yes

  No

  N/A

• Is there suitable local fire extinguishing media?

  Yes

  No

  N/A

• Does the fire alarm require temporary deactivation?

  Yes

  No

• Follow the Temporary Alarm Deactivation procedure

  Compliant

  Non-Compliant

  N/A

• Is the work area suitable to allow clear evacuation for the work party and others in the building?

  Yes

  No

  N/A

• Is there a suitable local means of raising the alarm?

  Yes

  No

  N/A

• Is a Fire Watch designated?

  Yes

  No

  N/A

• Fire Watch must be in place for 1 Hour following Hot Works

• Name of designated Fire Watch

  Sign

• Confirm appropriate PPE is available and will be worn during works

  Yes

  No

  N/A

• Does the job involve: WORK AT HEIGHT

  Yes

  No

Work at Height

• Will the job involve work from a Ladder?

  Yes

  No

• Is the ladder in suitable condition?

  Yes

  No

  N/A

• Is it securely footed and stable?

  Yes

  No

  N/A

• Has the 1:4 rule been followed?

  Yes

  No

  N/A

• IF being used as access to a platform / work area - does it extend suitably above the level being accessed?

  Yes

  No

  N/A

• Will work be carried out from / while stood on the ladder?

  Yes

  No

• Confirm the following controls:

• 3 points of contact can be maintained

  Yes

  No

  N/A

• The ladder will be footed by another individual

  Yes

  No

  N/A

• Only readily held or stowed tools / materials / equipment shall be carried or used

  Yes

  No

  N/A

• There is no requirement to extend / lean to the side

  Yes

  No

  N/A

• The job is limited in scope - Work from a ladder is the most reasonably practicable solution to access this work safely

  Yes

  No

  N/A

• Will the work be carried out from a Scaffold?

  Yes

  No

• Is the scaffold appropriately tagged as safe to use?

  Yes

  No

  N/A

• Is the access clear on and around the ladder / steps?

  Yes

  No

  N/A

• Is the working platform free of trip hazards / excess materials?

  Yes

  No

  N/A

• Are there any unsuitable gaps in the platform boards or hand rails?

  Yes

  No

  N/A

• Does the scaffold appear un-tampered-with and in good order?

  Yes

  No

  N/A

• Can equipment / materials be taken up the scaffold safely?

  Yes

  No

  N/A

• Can equipment / materials be laid down safely if required?

  Yes

  No

  N/A

• Is there a risk of material falling from the platform or from work being carried out?

  Yes

  No

• Have suitable measures been agreed to control materials from falling from height?<br>(e.g. through placing items in buckets; through tethering)

  Yes

  No

  N/A

• If there is residual chance for materials to fall, has a suitable barrier been placed beneath the work area and any potentially affected persons informed?

  Yes

  No

  N/A

• Will the work be carried out from a Mobile Elevated Working Platform (MEWP)?

  Yes

  No

• Is the operator fully trained & competent?<br>(IPAF Card holder, or other appropriate qualification)

  Yes

  No

  N/A

• Is the MEWP in suitable condition, with LOLER inspection in date?

  Yes

  No

  N/A

• Will the MEWP be used on level ground?

  Yes

  No

  N/A

• Can the platform be positioned such that the work can be carried out without reaching or leaning significantly over the side of the basket?

  Yes

  No

  N/A

• Will users wear appropriate harness / fall-restraint harness, as required?<br>[Note: A harness is required for any non-vertical MEWP (Scissor Lift) and in a vertical MEWP where risk assessment indicates]

  Yes

  No

  N/A

• Will the work be carried out using a Harness / Lanyard as the primary means of protection?

  Yes

  No

• Is the operator fully trained & competent?

  Yes

  No

  N/A

• Are there suitable attachment points for the lanyard?

  Yes

  No

  N/A

• Has the most appropriate lanyard type & length been selected?

  Yes

  No

  N/A

• Is there a written and approved Rescue Plan?

  Yes

  No

  N/A

• Has the area beneath been barriered off appropriately?

  Yes

  No

  N/A

• Are tools / equipment / materials suitably protected from falling to ground?

  Yes

  No

  N/A

• Confirm that the job is limited in scope - and that Work at Height with a Harness is the most reasonably practicable solution to access this work safely

  Yes

  No

  N/A

• Does the job involve: HAZARDOUS MATERIALS

  Yes

  No

Hazardous Materials

• Is the operator / Are the operators suitably trained & competent to handle / work with the material?

  Yes

  No

  N/A

• Are there suitable spill containment & absorption materials close by the work area?

  Yes

  No

  N/A

• Is the Safety Data Sheet (SDS) readily available?

  Yes

  No

  N/A

• Is there a COSHH Assessment available?

  Yes

  No

  N/A

• Are operatives involved briefed on the SDS & COSHH Assessment?

  Yes

  No

  N/A

• Has the risk of environmental contamination been suitably controlled?<br>[Detail any specific controls]

  Yes

  No

  N/A

• Is there suitable PPE available?

  Yes

  No

  N/A

• Confirm that all involved operatives have and will wear appropriate PPE

  Yes

  No

  N/A

• Confirm that other personnel in / nearby the work area are appropriately informed of the hazardous material being worked with

  Yes

  No

  N/A

• IF there is potential to affect other personnel in the immediate or surrounding area, confirm that they will be suitably informed, work paused or stopped, and otherwise prevented from being adversely affected by this work

  Yes

  No

  N/A

• Does the job involve: EQUIPMENT ISOLATION

  Yes

  No

Equipment Isolation

• The LOTOTO Procedure must be followed.
  Refer to LOTOTO Guidance Documents for Equipment where available

• Does the job involve: Electrical Isolations

  Yes

  No

• Define the following:

• Location of Isolation(s)

• Method of Isolation(s)

• Confirm that Upstream and Downstream equipment has been considered in the required isolations

  Yes

  No

  N/A

• Confirm that Ancillary or Connected equipment has been considered in the required isolations

  Yes

  No

  N/A

• Does the job involve: Air System Isolations

  Yes

  No

• Define the following:

• Location of Isolation(s)

• Method of Isolation(s)

• Confirm that Upstream / Downstream equipment has been considered in the required isolations

  Yes

  No

  N/A

• Confirm that Ancillary or Connected equipment has been considered in the required isolations

  Yes

  No

  N/A

• Does the job involve: Other Valve Type Isolations

  Yes

  No

• Define the following:

• Location of Isolation(s)

• Method of Isolation(s)

• Confirm that Upstream / Downstream equipment has been considered in the required isolations

  Yes

  No

  N/A

• Confirm that Ancillary or Connected equipment has been considered in the required isolations

  Yes

  No

  N/A

• Have residual energies been released?

  Yes

  No

  N/A

• Have hot surfaces or parts been allowed to cool?

  Yes

  No

  N/A

• Have lines been drained down?

  Yes

  No

  N/A

• State any additional precautions

• Does the job involve: ELECTIRCAL WORKS

  Yes

  No

Electrical Works

• Is the operative / are the operatives suitably qualified & competent to undertake electrical works?

  Yes

  No

  N/A

• Is there a diagram of the electrical system?

  Yes

  No

  N/A

• Do you have suitable, proven test equipment?

  Yes

  No

  N/A

• Confirm the following:

• Multiple feeds made safe

  Yes

  No

  N/A

• Live Conductors from incoming supplies made safe <br>(e.g. feed to isolators)

  Yes

  No

  N/A

• Effective Isolations in place<br>(e.g. Circuit breaker(s) locked out; Fuse(s) withdrawn; Isolator(s) locked off; or other Isolation)<br>[State Details]

  Yes

  No

  N/A

• Equipment efficiently connected to earth<br>[State Details]

  Yes

  No

  N/A

• Circuit tested and found to be dead

  Safe

  At Risk

  N/A

• Caution notices posted where required<br>[State Details]

  Yes

  No

  N/A

• Other hazards (e.g. capacitors, static etc.) made safe<br>[State Details]

  Yes

  No

  N/A

• State any additional precautions

• I, the Authorising Person, give authorisation for the work specified above to be carried out – in accordance with the relevant Risk Assessment, Standard Operating Procedure, Control Measures, Method Statement(s), and/or precautions detailed above.

• Date and Time

  Date

• Full Name and Signature of Authorising Person

  Sign

Permit Acceptance

• I, the Responsible Person, will ensure that work specified above will be carried out in accordance with all relevant risk assessment(s), method statement(s) and any precautions detailed above.

• Full Name and Signature of Responsible Person

  Sign

• Are other personnel involved in this work?

  Yes

  No
Acceptance of other personnel involved in carrying out this work

• I understand the work plan - including the limitations, restrictions, and controls. I will follow all precautions identified and stop / report if I consider there to be uncontrolled or unacceptable risk.

• Add signature

  Sign

• I, the Responsible Person, confirm that the work has been completed / partially completed, checked, and the area left in a safe and tidy condition.

• Full Name and Signature of Responsible Person

  Sign

• I, the Authorising Person, confirm that I have inspected the work area.
  It is in a safe and suitable condition.
  This Permit is hereby cancelled.

• Full Name and Signature of Authorising Person

  Sign

• Date and Time

  Date