Title Page

  • Site conducted

  • Business unit

  • Date Work is taking place? (Permit is valid for 24hrs).

  • Prepared by

  • Location
  • What is the task? (Brief description of the work taking place)

  • What is the name of the contractor?

  • Is the contractor performing the task approved on the supplier database?

  • Address issue with purchasing department

  • Name of the site workgroup manager/supervisor.

  • What is the site workgroup manager/supervisor's telephone number

  • Are all members of the workgroup site inducted?

  • Perform QSHE 121b Contractor induction and retain evidence.

  • Are the electrician(s) NICEIC or similar qualified? Have all work related licenses and skills cards been witnessed, in date and evidence taken?

  • What evidence do they have to show they are competent to perform the task?

  • Risk Assessment/Method Statement received and approved

  • Review risk assessment and ensure all precautions stated are in place before work commences

Significant Hazards and Control Measures . (See Risk Assessment and Method Statement for full details)

  • Are you using extension leads?

  • If using any extension leads, you MUST not overload any units, have extensions fed from extensions (Daisy Chaining) and any cabling on spools must be fully wound out to prevent overheating

  • Type of electrical work

  • Hazards

  • Precautions

Other Non- Electrical Hazards

  • Are you working at height or task include hot work (Welding, soldering, generating heat/sparks)

  • You musht complete additional permits (183b Hot Work / 183 Working at Height)

  • Are you lone Working

  • What precautions are you taking to ensure your health and safety?

  • Are you working outside.

  • What are the weather conditions

Waste Disposal

  • Are you generating wastes as part of your task.

  • How are you disposing of the waste?

  • Name of waste carrier arranged to collect waste.

Emergency Preparedness

  • What are your First Aid Arrangements?

  • Have the First Aid team been made aware of your work on site?

  • First aid team notified

Authorisation and Acceptance for task to commence

  • On behalf of Schenker Ltd, I authorise the work to be undertaken having personally examined the work site and all the documentation and confirm the precautions take are adequate and conform to DB Schenker's QSHE Policy

  • Issued by:

  • Authorised Signature

  • On behalf of Contract Supervisor/Manager I have personnally examined the work location and have read and understood this form. I undertake to ensure that all works are carried out in accordance with this permit, DB Schenker's QSHE Policy

  • Issued To:

  • Authorised Signature

  • End of Day, worksite safe declaration
  • Work progressing to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations/lock out tags have been removed and services restored (If work complete). The area is safe to recommence normal working activities.

  • Work site issues must be addressed before the end of day worksite declaration is signed.

  • Confirmed by Contractor:

  • Authorised Signature

  • Witnessed by (Schenker):

  • Authorised Signature

  • Date and Time of Sign Off

  • Any final remarks/Comments:

Job Completion Declaration

  • Task Complete

  • Return to end of day, worksite safe declaration section.

  • Work completed to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations/lock out tags have been removed and services restored (If work complete). The area is safe to recommence normal working activities.

  • Confirmed by Contractor:

  • Authorised Signature

  • Witnessed by (Schenker):

  • Authorised Signature

  • Date and Time of Sign Off

  • Any final remarks/Comments:

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.