Cold work permit

• Company name

• Site/project

• Prepared by

• Job task Location
  Address

Job description

• What is the job description ?

Tools and equipment?

• What is the tools and equipment used in this job?

Ppe

• Availability

Type of ppe

• What type of ppe

Specific PPE

• What's the specific PPE?

Work at heights

• Working at heights required

  Select Yes No N/A

  • Yes
  • No
  • N/A

• True or false: Workers are required to undergo specific training before being issued a cold work permit.

Confined space

• Confined space entry requirements?

  Select Yes No N/A

  • Yes
  • No
  • N/A

Excavation

• Excavation description

Method of statement and risk assessment

• MS AND RA
Accepted and released

• Accepted and released by HSE

  Sign

Site Eng. Accepted and agreed

• Site Eng

  Sign

Consultant HSE APPROVAL

• Consultant HSE Eng.

  Sign

• I/We confirm that the information provided in this declaration is true and accurate to the best of my/our knowledge. I/We understand and agree to comply with all applicable safety regulations and procedures related to the work being performed. I/We will ensure that all personnel involved in the work are adequately trained and informed about the hazards and safety precautions.

  Yes

  No

  N/A

• Declared and agreed

• I/We confirm that the work described in the previously submitted work permit application has been completed, and the worksite has been cleared. All equipment and materials have been removed, and the area is now safe for normal operations.

  Yes

  No

  N/A

• undefined

• Attendances 1

Attendances 2

• Attendances 2