Title Page

  • Permit No.

  • Location
  • Created on

  • Prepared by

Work Details

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?

  • Specify other work

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

  • Specify action required

Personnel Details

  • Who is the Responsible Person?

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

  • Will others be involved in the work?

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

Hazards and Precautions

Hazards & Precautions: General

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

  • 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?

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

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

  • Confirm the following:

  • Operatives involved in this work are briefed to the SOP

  • The SOP is available to the Operatives for reference

  • The SOP will be followed for this work

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

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

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

  • Is all required PPE available and in suitable condition?

Hazards & Precautions: Specific

  • The following types of work require specific consideration:

  • Does the job involve: HOT WORK

Hot Work

  • Is the floor and surrounding area clear of combustible materials

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

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

  • Is there suitable local fire extinguishing media?

  • Does the fire alarm require temporary deactivation?

  • Follow the Temporary Alarm Deactivation procedure

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

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

  • Is a Fire Watch designated?

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

  • Name of designated Fire Watch

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

  • Does the job involve: WORK AT HEIGHT

Work at Height

  • Will the job involve work from a Ladder?

  • Is the ladder in suitable condition?

  • Is it securely footed and stable?

  • Has the 1:4 rule been followed?

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

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

  • Confirm the following controls:

  • 3 points of contact can be maintained

  • The ladder will be footed by another individual

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

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

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

  • Will the work be carried out from a Scaffold?

  • Is the scaffold appropriately tagged as safe to use?

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

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

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

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

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

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

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

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

  • 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?

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

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

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

  • Will the MEWP be used on level ground?

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

  • 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]

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

  • Is the operator fully trained & competent?

  • Are there suitable attachment points for the lanyard?

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

  • Is there a written and approved Rescue Plan?

  • Has the area beneath been barriered off appropriately?

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

  • 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

  • Does the job involve: HAZARDOUS MATERIALS

Hazardous Materials

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

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

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

  • Is there a COSHH Assessment available?

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

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

  • Is there suitable PPE available?

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

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

  • 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

  • Does the job involve: EQUIPMENT ISOLATION

Equipment Isolation

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

  • Does the job involve: Electrical Isolations

  • Define the following:

  • Location of Isolation(s)

  • Method of Isolation(s)

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

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

  • Does the job involve: Air System Isolations

  • Define the following:

  • Location of Isolation(s)

  • Method of Isolation(s)

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

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

  • Does the job involve: Other Valve Type Isolations

  • Define the following:

  • Location of Isolation(s)

  • Method of Isolation(s)

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

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

  • Have residual energies been released?

  • Have hot surfaces or parts been allowed to cool?

  • Have lines been drained down?

  • State any additional precautions

  • Does the job involve: ELECTIRCAL WORKS

Electrical Works

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

  • Is there a diagram of the electrical system?

  • Do you have suitable, proven test equipment?

  • Confirm the following:

  • Multiple feeds made safe

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

  • 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]

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

  • Circuit tested and found to be dead

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

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

  • State any additional precautions

Authorisation to Work

  • 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

  • Full Name and Signature of Authorising Person

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

  • Are other personnel involved in this work?

  • 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

Handback & Cancellation

  • 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

  • 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

  • Date and Time

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.