Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Task /Activity Description
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Persons Involved
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Is the permit completed properly without any corrections or alterations? (All information completed, date, time, discipline, contractor, company name, type of work and confined space entry)
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Is the area of work clearly defined? incl. Business Unit name, plant name, building number/name, equipment number or name and work order number (if applicable)
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Does the work permit have a single task description and clearly noted what needs to be done? e.g. Do grinding work on the tank as oppose to “do repairs on the tank. (Check if a copy of the permit is available on the plant)
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Has each discipline completed a Pre-Task Risk Assessment? Is this available?
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Are additional permits/certificates or relevant documentation attached to the permit? Check that all applicable documents are attached to the permit e.g. spade list, vessel entry log, excavation certificate, etc.
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Has all waste generated by this task been identified and the method of disposal noted on the permit? (verify means of waste segregation measures)
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Are hot work restrictions clearly identified and the permit signed by higher authority? (if applicable) (verify on the plant)
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Is the permit authorised and valid? (Check the date on the permit)
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Are the permits issued at the place of work?
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Have all the hazards that might still exist been identified?
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Has all the protective equipment (PPE) been identified and is it adequate, available and being used? (verify on the plant)
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Has all the protective equipment (PPE) been identified and is it adequate, available and being used? (verify on the plant)
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Is there any restriction on tools identified and additional precautions noted if applicable?<br>(verify on the plant) <br>
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Are all role players (Permit Issuers & Permit Acceptors) authorised and competent (Check if all authorisations are still valid?)
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Have all role players been trained on the Permit to Work procedure (Proof of training available)?
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Is the permit signed off upon completion of the task? (check if all role players have signed off)
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Is the Permit Issuer on-site and available? Have any conditions changed?