Cold work permit

• Company name

• Site/project

• Prepared by

• Job task Location

Job description

• What is the job description ?

Tools and equipment?

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

• Calibration certificate

  Yes

  No

  N/A

• Driver name

• Operation/driving license

  Media

Ppe

• Vest

• Safety shoes

• Helmit

• Special PPE

• Safety Induction: 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

• Training

  Yes

  No

  N/A

• PPE

  Yes

  No

  N/A

• Rescue equipment

  Yes

  No

  N/A

• 2 ways of Communication

  Yes

  No

  N/A

Work at heights

• scaffold inspected and Tagged

  Yes

  No

  N/A

• Fall prevention requirement

  Yes

  No

  N/A

• Ladders and Scaffolds:

  Yes

  No

  N/A

• Personal Protective Equipment (PPE):

  Yes

  No

  N/A

• Fall Arrest Systems:

  Yes

  No

  N/A

• Guardrails and Safety Nets:

  Yes

  No

  N/A

• Yes

  No

  N/A

Rigging and lifting

• Rigging certificate

  Yes

  No

  N/A

• Crane operator license

  Yes

  No

  N/A

• Crane calibration certificate

  Yes

  No

  N/A

• wind speed checked

  Select Yes No N/A

  • Yes
  • No
  • N/A

Excavation

• Excavation description

• Excavation checklist

  Yes

  No

  N/A

• Underground services clearance

  Yes

  No

  N/A

Method of statement and risk assessment

• MS AND RA

  Yes

  No

  N/A

• Document number

Accepted and released

• Permit Accepted and released by HSE Team

  Sign

Permit Accepted and released by Site Engineer\Manager

• Site Eng\Manager

  Sign

APPROVAL by Consultant HSE Engineer

• Consultant HSE Engineer

  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

• Site Engineer\Supervisor

  Sign

• 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

• Declared and agreed

• Site Engineer\Supervisor

  Sign

• Attendances evidence

  Media

Additional evidence

• Attendances 2

  Media