Dignity Manufacturing Permit to Work

• Name of Dignity Employee Issuing Permit to Work

• Name of Contractor/Company

• Contractor Name/Names

• Contractor Name/Names

• Contractor email address

• Contractor contact number

• Location/Work Site

  Factory 1

  Factory 2

  Warehouses

  Full Site

• Inspection Date & Start Time

  Date

• Contractor RAMS & public liability insurance documents received

  Yes

  No

• Dignity Employee to sign giving authorisation for the work to be carried out and has notified the relevant personnel

  Sign

• Contractor to sign to say that they understand the conditions of this permit

  Sign

• Is the work been carried in an area that contains asbestos (Check asbestos register if unsure)

  Yes

  No

• Seek assistance from Management to issue an Asbestos Work Permit

• Work Activity Title

• What level of risk is the work?

  High

  Medium

  Low

• Type of Work

  Select General Hot Work Confined Space Excavation Plant Isolation Work at Heights Live Electrical Maintenance Work Other

  • General
  • Hot Work
  • Confined Space
  • Excavation
  • Plant Isolation
  • Work at Heights
  • Live Electrical Maintenance Work
  • Other

• Start of Work

  Date

Safety Precautions (To be completed by the person responsible for carrying out the work)

• Have you been inducted to the area where the works are taking place

  Yes

  No

• Have you received instruction of the site safety rules

  Yes

  No

• PPE is mandatory in work areas of Dignity Manufacturing. Do you know the requirements for the location where work is being undertaken?

  Yes

  No

• Is the workforce qualified to carry out the task?

  Yes

  No

• If working in a confined space have air samples been taken?

  Yes

  No

• Is any electrical supply isolated? Working in accordance with with Electricity Work reg's

  Yes

  No

• Is voltage detection instrument required?

  Yes

  No

• Isolator locked off / tagged out? Work in accordance with I.E.E Wiring regs. (BS7671)

  Yes

  No

• Are ladders or scaffolding required? If yes, are they in a safe condition and ready to use?

  Yes

  No

• Is a license required and in place for scaffold?

  Yes

  No

• Are you aware of Dignity's evacuation procedure?

  Yes

  No

• Is there a risk of falling objects?

  Yes

  No

• Are you required to work on a fragile roof? If so are details and dangers explained?

  Yes

  No

• Are fire extinguishes associated with the task available?

  Yes

  No

• Are people undergoing work trained in the use of fire extinguishers?

  Yes

  No

• Have flammable liquids / materials been removed from the working area?

  Yes

  No

• Have gas cylinders been properly secured ?

  Yes

  No

• Is safe access and egress confirmed?

  Yes

  No

• Are persons undertaking the work trained and supplied with breathing apparatus?

  Yes

  No

Precautions

• Scaffolding checked and signed off

  Yes

  No

  N/A

• Ladder checked (to be tied / footed)

  Yes

  No

  N/A

• Area safe, clean and cordoned off?

  Yes

  No

  N/A

• Correct fire protection within 3m?

  Yes

  No

  N/A

• Fire guard required?

  Yes

  No

  N/A

• Area clear of combustible materials?

  Yes

  No

  N/A

• Sewers, drains, sealed within 6m?

  Yes

  No

  N/A

PPE

• Safety glasses

  Yes

  No

• Hearing protection

  Yes

  No

• Safety footwear

  Yes

  No

• Hi viz

  Yes

  No

• Gloves

  Yes

  No

• Hard hat

  Yes

  No

• RPE

  Yes

  No

• Safety harness

  Yes

  No

Service to be isolated

• Fire Alarm / Zone

  Yes

  No

• Electrics

  Yes

  No

• Gas? If so specify

• Hazardous Chemicals

  Yes

  No

COSHH and Lone working

• Has COSHH data been supplied with substances?

  Yes

  No

• Have COSHH precautions been identified and implemented

  Yes

  No

• Is work been carried out by a lone worker

  Yes

  No

• If Yes is monitoring required

• undefined

Hand back

• Contractor sign to certify that all work is completed and in safe condition. Upon signing the permit will be closed and any other works require a separate permit

  Sign

• Dignity employee to sign to certify that work is complete and the area is left safe and clean for operations to recommence

  Sign