• Document No.

  • Work description

  • Client / Site

  • Conducted on

  • Assessment done by

  • Location
  • Other participants

Work order number



  • Weather

  • Noise

  • Lighting

  • Ignition sources

  • Work at height

  • Oxygen enrichment

  • Oxygen Deficiency

  • Confined space NOTE: if ticked Confined Space Permit must be filled out

Dangerous goods

  • Flammable

  • Oxidising

  • Inert

  • Mobile equipment & machines

Manual Handling

  • Repetition

  • Weight limits

  • Heat/Cold exposure

Trip Hazard

  • Uneven Ground

  • Slippery Floor

  • Cluttered Work Space


  • Connections

  • Cords

  • In-test date


  • Condition

  • Tagged

  • Ladder

  • Work on Pressurised Equipment

  • Other

  • 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

  • Completed by

  • Approved by (or Customer)

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