Title Page

  • Permit Number

  • Contracting Company

  • Location
  • Conducted on

  • Prepared by

  • Scope of works

  • Permit valid from

  • Permit valid to

Potential Hazards and Controls

  • Depressurizing

  • Draining

  • Adequate lighting

  • Safety tags and locks

  • Electrical isolation

  • Mechanical isolation

  • Exposure to moving/rotating machinery

  • Confined space

  • Fall protection

  • Standby man

  • Ventilate properly

  • Warning notice

  • Potential flammable/explosive atmosphere

  • Potential high temperature

  • Potential high pressure

  • Potential exposure to hazardous materials

  • Excavation works

Personnel Protective Equipment

  • Select PPE to be used

  • Other PPE

Work Authorization

  • Full Name and Signature of Issuer

  • Full Name and Signature of Performer

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.