Cold Work Permit

• Permit Number

• Contracting Company

• Location
  Address

• Conducted on

  Date

• Prepared by

• Scope of works

• Permit valid from

  Date

• Permit valid to

  Date

Potential Hazards and Controls

• Depressurizing

  Yes

  No

  N/A

• Draining

  Yes

  No

  N/A

• Adequate lighting

  Yes

  No

  N/A

• Safety tags and locks

  Yes

  No

  N/A

• Electrical isolation

  Yes

  No

  N/A

• Mechanical isolation

  Yes

  No

  N/A

• Exposure to moving/rotating machinery

  Yes

  No

  N/A

• Confined space

  Yes

  No

  N/A

• Fall protection

  Yes

  No

  N/A

• Standby man

  Yes

  No

  N/A

• Ventilate properly

  Yes

  No

  N/A

• Warning notice

  Yes

  No

  N/A

• Potential flammable/explosive atmosphere

  Yes

  No

  N/A

• Potential high temperature

  Yes

  No

  N/A

• Potential high pressure

  Yes

  No

  N/A

• Potential exposure to hazardous materials

  Yes

  No

  N/A

• Excavation works

  Yes

  No

  N/A

Personnel Protective Equipment

• Select PPE to be used

  Select Working Gloves PVC Gloves Face shields Goggles Ear plugs Gas masks Other

  • Working Gloves
  • PVC Gloves
  • Face shields
  • Goggles
  • Ear plugs
  • Gas masks
  • Other

• Other PPE

Work Authorization

• Full Name and Signature of Issuer

  Sign

• Full Name and Signature of Performer

  Sign