Dres clearance permit audit form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 Permit being audited

• 1.01 Clearance permit number

• 1.02 Clearance permit being audited is

  Open

  closed

2.0 Clearance permit form. (a no answer requires resolution and comment)

• 2.01 Equipment listed?

  Yes

  No

  N/A

• 2.02 Revision numbers filled in?

  Yes

  No

  N/A

• 2.03 Page numbers filled in?

  Yes

  No

  N/A

• 2.04 Requested by name different than prepared by name?

  Yes

  No

  N/A

• 2.05 Prepared by name different than isolation completed by name?

  Yes

  No

  N/A

• 2.06 Isolation completed by, date, and time Line signed?

  Yes

  No

  N/A

• 2.07 Ground/equipment referenced?

  Yes

  No

  N/A

3.0 Permit holder accepted (no answer requires resolution and comment)

• 3.01 Permit holders name(s) legible?

  Yes

  No

  N/A

• 3.02 Permit holder lock number filled in and legible?

  Yes

  No

  N/A

• 3.03 Description of work to be done noted?

  Yes

  No

  N/A

• 3.04 Clearance safety -verified and accepted initials and dated?

  Yes

  No

  N/A

• 3.05 Crew sign on column filled in (y or n)

  Yes

  No

  N/A

4.0 Permit holder releasing (no answer requires resolution and comment)

• 4.01 ADE column, if on was it signed off?

  Yes

  No

  N/A

• 4.02 Clearance released initial and date?

  Yes

  No

  N/A

• 4.03 Work complete YES or NO?

  Yes

  No

  N/A

5.0 Final release ( no answer requires resolution and comment)

• 5.01 Final clearance released by signed, dated and time?

  Yes

  No

  N/A

• 5.02 Final clearance reviewed by signed and dated?

  Yes

  No

  N/A

• 5.03 Tags removed by signed, and dated?

  Yes

  No

  N/A

• 5.04 Permit closed by signed, and dated?

  Yes

  No

  N/A

6.0 Tag list form ( no answer requires resolution and comment)

• 6.01 Are all placed by tags initialed?

  Yes

  No

  N/A

• 6.02 Are all removed by tags initialed?

  Yes

  No

  N/A

7.0 Crew sign on sheet ( no answer requires resolution and comment)

• 7.01Page number filled in?

  Yes

  No

  N/A

• 7.02Revision numbers filled in?

  Yes

  No

  N/A

• 7.03 Permit holder line number filled in?

  Yes

  No

  N/A

• 7.04 Lock number filled in?

  Yes

  No

  N/A

• 7.05 Permit holder description of work noted?

  Yes

  No

  N/A

• 7.06 Permit holder signed on initialed and dated?

  Yes

  No

  N/A

• 7.07 Permit holder close crew sign-on sheets initialed and dated?

  Yes

  No

  N/A

• 7.08 Crew sign-on signed on initialed and dated?

  Yes

  No

  N/A

• 7.09 Lock number filled in?

  Yes

  No

  N/A

• 7.10 Crew sign-on signed description of work noted?

  Yes

  No

  N/A

• 7.11 Crew sign-off initialed and dated?

  Yes

  No

  N/A

• 7.12 If ON was all ADE tags off?

  Yes

  No

  N/A

8.0 Permission to test operate form ( no answer requires resolution and comment)

• 8.01 Was sign on withdrawn on clearance permit and highlighted?

  Yes

  No

  N/A

• 8.02 If job continued was sign on reinstated on clearance permit?

  Yes

  No

  N/A

• 8.03 Page numbers filled in?

  Yes

  No

  N/A

• 8.04 Permission to test operate number filled in?

  Yes

  No

  N/A

• 8.05 Clearance permit number, revision, unit and date filled in?

  Yes

  No

  N/A

• 8.06 Grounds checked yes or no?

  Yes

  No

  N/A

• 8.07 Test requested by (permit holder) filled in?

  Yes

  No

  N/A

• 8.08 Permission to perform test granted to filled in?

  Yes

  No

  N/A

• 8.09 Equipment to be tested filled in?

  Yes

  No

  N/A

• 8.10 Description for test filled in?

  Yes

  No

  N/A

• 8.11 Permission to test operate start and terminated date and time filled in?

  Yes

  No

  N/A

• 8.12 Description of tag removed for test and tag numbers filled in?

  Yes

  No

  N/A

• 8.13 We're all active permit holders listed (proper line #)?

  Yes

  No

  N/A

• 8.14 Permit holders initialed, affected yes/no filled in?

  Yes

  No

  N/A

• 8.15 Approved for test lined signed?

  Yes

  No

  N/A

• 8.16 Tags removed by initialed?

  Yes

  No

  N/A

• 8.17 Personnel associated with test initial on and off?

  Yes

  No

  N/A

• 8.18 Was test completed lined signed?

  Yes

  No

  N/A

• 8.19 We're tags reinstalled (initialed) or tags not rehung box checked?

  Yes

  No

  N/A

• 8.20 Affected permit holders verified safe test box initialed?

  Yes

  No

  N/A

• 8.21 Was test closed signed?

  Yes

  No

  N/A

9.0 Clearance permit modification form ( no answer requires resolution and comment)

• 9.01 Clearance permit modification page number filled in?

  Yes

  No

  N/A

• 9.02 Clearance permit number and revision filled in ?

  Yes

  No

  N/A

• 9.03 Modification requested by (permit holder) filled in?

  Yes

  No

  N/A

• 9.04 Reason for modification noted?

  Yes

  No

  N/A

• 9.05 Tags to be added (installed by) filled in?

  Yes

  No

  N/A

• 9.06 Tags to be added (verified by requesting permit holder) filled in?

  Yes

  No

  N/A

• 9.07 Tags to be (removed by) filled in?

  Yes

  No

  N/A

• 9.08 We're all active permit holders listed and initialed (proper line#)?

  Yes

  No

  N/A

• 9.09 Issuing authority (ENPR team leader) signed and dated?.

  Yes

  No

  N/A

10.0 auditor comments

• 10.01 comments

• 10.02 Person auditing clearance

  Sign