Information
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Document No.
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Work description
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Client / Site
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Conducted on
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Assessment done by
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Location
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Other participants
Work order number
Hazards
Environment
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Weather
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Noise
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Lighting
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Ignition sources
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Work at height
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Oxygen enrichment
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Oxygen Deficiency
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Confined space NOTE: if ticked Confined Space Permit must be filled out
Dangerous goods
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Flammable
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Oxidising
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Inert
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Mobile equipment & machines
Manual Handling
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Repetition
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Weight limits
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Heat/Cold exposure
Trip Hazard
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Uneven Ground
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Slippery Floor
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Cluttered Work Space
Electrical
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Connections
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Cords
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In-test date
Tools
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Condition
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Tagged
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Ladder
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Work on Pressurised Equipment
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Other
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Work Permit is required for 1 high risk or 5 medium risks severities. Control measures are to be used to improve safety and lower severity. SEVERITY DEFINITIONS:
HIGH: Frequent exposure for extended periods, high probability of injury, high consequence with injury. MEDIUM: Occasional exposure, medium probability of injury with medium consequences. LOW: Little risk of injury, low exposure with low consequences. -
Work Permit REQUIRED
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Completed by
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Approved by (or Customer)
