Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Task /Activity Description

  • Persons Involved

  • 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)

  • 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)

  • 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)

  • Has each discipline completed a Pre-Task Risk Assessment? Is this available?

  • 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.

  • Has all waste generated by this task been identified and the method of disposal noted on the permit? (verify means of waste segregation measures)

  • Are hot work restrictions clearly identified and the permit signed by higher authority? (if applicable) (verify on the plant)

  • Is the permit authorised and valid? (Check the date on the permit)

  • Are the permits issued at the place of work?

  • Have all the hazards that might still exist been identified?

  • Has all the protective equipment (PPE) been identified and is it adequate, available and being used? (verify on the plant)

  • Has all the protective equipment (PPE) been identified and is it adequate, available and being used? (verify on the plant)

  • Is there any restriction on tools identified and additional precautions noted if applicable?<br>(verify on the plant) <br>

  • Are all role players (Permit Issuers & Permit Acceptors) authorised and competent (Check if all authorisations are still valid?)

  • Have all role players been trained on the Permit to Work procedure (Proof of training available)?

  • Is the permit signed off upon completion of the task? (check if all role players have signed off)

  • Is the Permit Issuer on-site and available? Have any conditions changed?

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.