IThra Work Permit Review Form

• Conducted on

  Date

• Prepared by

• Location
  Address

Permit Authorization and Type:

• INSTRUCTIONS
  _______________________________________________________________________________________________________________________________
  1. Please answer the questions below by typing in your responses and answer "Yes," "No," or "N/A" on the questions below.
  2. Add photos and notes by clicking on the paperclip icon.
  3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority, and due date.
  4. Complete audit by providing digital signature.
  5. Share your report by exporting as PDF, Word, Excel or Web Link.

• Permit Issuer: Hassan Al Halal (778750), Mohammad Alalem (177386), Saad Al Khaldi (772976), Salem Al Khaldi (764124), Ahmed Mustafa (177387), Rashid Choudry (722489)

• Permit Type: Hot ( ) Cold ( ) Confined Space ( ) Release ( )

Work Discription:

• Permit No:

• Permit Type:

• Issuer Name:

• Work to be done:

• Equipment’s to be used:

• Date:

• Duration:

Document Review:

• 1) Correct Type of Work Permit Issued?

  Yes

  No

  N/A

• 2) Issuer's Certification Valid?

  Yes

  No

  N/A

• 3) Joint Site Inspection Conducted by Issuer & Receiver?

  Yes

  No

  N/A

• 4) Permit Properly Countersigned?

  Yes

  No

  N/A

• 5) Proper Gas Tests Recorded?

  Yes

  No

  N/A

• 6) Permit Properly Closed/Extended?

  Yes

  No

  N/A

• 7) Gas Testing Equipment Operational?

  Yes

  No

  N/A

General:

• 8) Permit Available At Site?

  Yes

  No

  N/A

• 9) Receiver/Delegate Available At Site?

  Yes

  No

  N/A

• 10) Receiver Certificate Valid?

  Yes

  No

  N/A

• 11) Work Scope Defined Properly?

  Yes

  No

  N/A

• 12) Equipment Properly Identified?

  Yes

  No

  N/A

• 13) Hazards Properly Defined?

  Yes

  No

  N/A

• 14) Precautions Properly Defined?

  Yes

  No

  N/A

• 15) Gas Test Properly Conducted?

  Yes

  No

  N/A

• 16) Receiver Following Permit Instructions?

  Yes

  No

  N/A

• 17) Emergency response plan communicated/ available?

  Yes

  No

  N/A

Job Specified:

• 18) Barricade/Warning Signs Adequate?

  Yes

  No

  N/A

• 19) Personal Protective Equip. Adequate?

  Yes

  No

  N/A

• 20) Issuer's Lockout/Hold Tag Adequate?

  Yes

  No

  N/A

• 21) Receiver's Lockout/Hold Tag Adequate?

  Yes

  No

  N/A

• 22) Stand-by Man Available?

  Yes

  No

  N/A

• 23) Equipment/Tools In Acceptable Condition?

  Yes

  No

  N/A

• 24) Scaffolding Acceptable?

  Yes

  No

  N/A

• 25) Acceptable Excavation Procedures?

  Yes

  No

  N/A

• 26) Equipment Isolated/Depressurized?

  Yes

  No

  N/A

• 27) Equipment Properly Grounded?

  Yes

  No

  N/A

• 28) Current Crane Inspection Sticker?

  Yes

  No

  N/A

• 29) Heavy Equipment Inspection sticker is Valid?

  Yes

  No

  N/A

• 30) Current Heavy Equip. Operator's License & Certification?

  Yes

  No

  N/A

• 31) Housekeeping/Storage Acceptable?

  Yes

  No

  N/A

• 32) Health Hazards Addressed?

  Yes

  No

  N/A

Fire Protection:

• 33) Fire Protection Equipment (FE) Adequate?

  Yes

  No

  N/A

• 34) Fire watch Available?

  Yes

  No

  N/A

• 35) Fire System Isolated/ covered for specific area?

  Yes

  No

  N/A

• 36) Additional firefighting equipment requires?

  Yes

  No

  N/A

Other Comments/Recommendations:

• Signature:

  Sign