Cygnus Permit to Work

• Site conducted

  Select

• Prepared by

• Location of Work

• Reason for Work

• Who is Undertaking the Work?

  Contractor

  School Site Team

• Company Name

• Suitable Risk Assessment Provided?

  Yes

  No

• School Site Team Members Name

• Is Schools Generic Risk Assessment Suitable for the Task?

  Yes

  No

• Has a Suitable Risk Assessment been Written?

  Yes

  No

• Planned Permit Start Time

  Date

• Planned Permit End Time

  Date

Work Type

• Asbestos

  Yes

  No

• Will Building Be Occupied During Work?

  Yes

  No

• What precautions have been put in place to protect building users? (Barriers, closed areas, notifications etc)

• What fibre containment control measures are contractor using? ( tents, enclosures, controlled drilling, air testing etc)

• If work involves Asbestos removal, have electrical, water and fire systems been isolated?

  Yes

  No

  N/A

• Work at Hight (Over 2m or Roof)

  Yes

  No

• Weather conditions Safe / Suitable?

  Yes

  No

• What are the conditions?

• Type of Access Equipment

  Ladder

  Stepladder

  Tower

  Cherry Picker (MEWP)

  Scaffolding

• Is LOLER in Date?

  Yes

  No

• Is Access Equipment Suitible for Local Conditions (slopes, banks, soft soil etc)

  Yes

  No

• Will Work Involve Going onto Roof?

  Yes

  No

• Type of Edge Protection / Fall Arrest System Used?

• Electrical

  Yes

  No

• Lock Out / Tag Out System Used?

  Yes

  No

• Works in Occupied Area / Kitchen? (loss of power to Fridges / Extraction etc)

  Yes

  No

• What Control Measures in Place?

• Confined Space (Loft, Manhole)

  Yes

  No

• Lone Working?

  Yes

  No

• List Control Measures in Place?

• Emergency Rescue Plan Considered

  Yes

  No

• What is Emergency Plan?

• Hot Works (grinding, welding, soldering etc)

  Yes

  No

• Is There Another Option Other Than Hot Works Availible?

  Yes

  No

• If Non Hot Option Is Used No Permit Is Required

  Ok

• Fire Extinguishers Availible

  Yes

  No

• 1 Hour Fire Watch Post Works

  Yes

  No

• Combustible Materials Removed from Area?

  Yes

  No

• In all Situations is the Works Area Suitably Barriered Off? (based on site users who are actually onsite)

  Yes

  No

  N/A

• List any Other Risks, Control Measures or Comments

Permit Opening Agreement

• Contractor Signed

  Sign

• School Site Team Signed

  Sign

• Estates / SBM / HT Signed (Approver)

  Sign

• Approval Date & Time ( Approver)

  Date

Permit Closure

• Contractor Signed

  Sign

• School Site Team Signed

  Sign

• Estates / SBM / HT Signed (Approver)

  Sign

• Permit Closure Date & Time (Approver)

  Date