Electrical Permit to work

• Permit No.

• Contracting Company

• Responsible Person

• Mobile phone number

• Additional Personal

• Location
  Address

• Conducted on

  Date

• Prepared by

• Activity Risk Level

  Low Risk

  Medium Risk

  High Risk

• Additional comments

General details

• Job Details

• Permit start

  Date

• Permit Estimated End

  Date

• PPE Requirements:

• Please state what PPE is required

  Select Safety boots Hard hats Safety Gloves Hi- Vis Clothing Hearing Protection Harness Respirator Eye Protection Life jackets

  • Safety boots
  • Hard hats
  • Safety Gloves
  • Hi- Vis Clothing
  • Hearing Protection
  • Harness
  • Respirator
  • Eye Protection
  • Life jackets

• Is there a risk assessment and method statement/SSOW available for the works?

  Yes

  No

• State Reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Are the works being undertaken by competent personal?

  Yes

  No

• Are these documents available?

  Yes

  No

• State Reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Are the appropriate insurance documents available?

  Yes

  No

• State reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Will this work encroach upon any other work, for which a permit to work will be/has been issued?

  Yes

  No

  N/A

• Has consultation and precautions taken place

  Yes

  No

• State reason why

• Do All Attendees have a valid DFDS Immingham Induction?

  Yes

  No

• State reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

Hazards and Precautions to be taken

• Is the area clear and free from hazards?

  Yes

  No

  N/A

• What actions are to be taken

• Can live working be avoided?

  Yes

  No

• State reason

• Will isolation procedures and checks be applied before start of works

  Yes

  No

  N/A

• Will the isolator be locked off and tagged?

  Yes

  No

  N/A

• Please provide details of LOTO

• Is there adequate protection against shocks and flashovers?

  Yes

  No

  N/A

• Is there sufficient light to work safely?

  Yes

  No

  N/A

• Will all procedures comply with the electricity at work regulations?

  Yes

  No

  N/A

• Is there adequate signage displayed?

  Yes

  No

  N/A

• Have the tools & equipment been inspected?

  Yes

  No

  N/A

• Are the weather conditions acceptable?

  Yes

  No

  N/A

• Additional comments

Authorization and Acceptance

• I confirm that I have accepted responsibility for the works to be carried out, and will ensure all health and safety and hygiene instructions are complied with. Competent authorised persons will carry out the works in accordance with the risk assessment & method statement

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• I am competent to authorise this permit, subject to the conditions indicated the works may proceed

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date

Hand Back and Cancellation

• I certify that

• undefined

  Select The work has been completed Equipment has been removed Plant and machinery has safely been returned to service Disable fire protection zones have been reinstated

  • The work has been completed
  • Equipment has been removed
  • Plant and machinery has safely been returned to service
  • Disable fire protection zones have been reinstated

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date