Title Page
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Site conducted
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Business unit
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Date Work is taking place? (Permit is valid for 24hrs).
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Prepared by
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Location
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What is the task? (Brief description of the work taking place)
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What is the name of the contractor?
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Is the contractor performing the task approved on the supplier database?
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Address issue with purchasing department
- Issue addressed with purchasing department
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Name of the site workgroup manager/supervisor.
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What is the site workgroup manager/supervisor's telephone number
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Are all members of the workgroup site inducted?
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Perform QSHE 121b Contractor induction and retain evidence.
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Are the electrician(s) NICEIC or similar qualified? Have all work related licenses and skills cards been witnessed, in date and evidence taken?
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What evidence do they have to show they are competent to perform the task?
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Risk Assessment/Method Statement received and approved
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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)
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Are you using extension leads?
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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
- Confirmed adherence to the rule.
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Type of electrical work
- Installation of a new circuit/fuse box etc.
- Replacement of an existing circuit/fuse box etc.
- Working on the electrics on a device controlling gas/water
- Voltage levels upto 250v
- Voltage levels above 250v
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Hazards
- Electric shock to you and others
- Site Electrics failure
- Fire Risk/Ignition of gas/fuel
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Precautions
- Electrical Isolation
- Earthing
- Tag out/Lock Out
- Non Conductive Tools
- Barriered Area/Caution Notices
- Fire Extinguishers/Fire Watchers
- Gas/fuel line isolation
Other Non- Electrical Hazards
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Are you working at height or task include hot work (Welding, soldering, generating heat/sparks)
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You musht complete additional permits (183b Hot Work / 183 Working at Height)
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Are you lone Working
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What precautions are you taking to ensure your health and safety?
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Are you working outside.
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What are the weather conditions
- Suitable - OK to proceed
- Not Suitable - Stop work and wait for improvement.
Waste Disposal
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Are you generating wastes as part of your task.
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How are you disposing of the waste?
- Schenker's waste arrangement (Segregation required)
- Own arrangement (Advise waste carrier's name)
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Name of waste carrier arranged to collect waste.
Emergency Preparedness
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What are your First Aid Arrangements?
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Have the First Aid team been made aware of your work on site?
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First aid team notified
Authorisation and Acceptance for task to commence
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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
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Issued by:
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Authorised Signature
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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
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Issued To:
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Authorised Signature
End of Day, worksite safe declaration
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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.
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Work site issues must be addressed before the end of day worksite declaration is signed.
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Confirmed by Contractor:
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Authorised Signature
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Witnessed by (Schenker):
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Authorised Signature
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Date and Time of Sign Off
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Any final remarks/Comments:
Job Completion Declaration
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Task Complete
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Return to end of day, worksite safe declaration section.
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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.
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Confirmed by Contractor:
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Authorised Signature
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Witnessed by (Schenker):
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Authorised Signature
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Date and Time of Sign Off
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Any final remarks/Comments: