Title Page

  • Conducted on

  • Prepared by

  • Location



  • What works will be undertaken?

  • Special Tools / Equipment to be Used

  • Job Location / Plant Identification Number

  • Is any other work currently being undertaken that may interact or affect this permit? (Quote Permit numbers where applicable)

This Permit is only Valid when all sections are complete. If you are in doubt or don't understand, then please ask. Remember, all accidents are preventable and it is people who get hurt and suffer pain. Please use this permit in the spirit intended to protect yourself and others. Please ensure that you sign this permit to work. DO NOT PROCEED WITH YOUR WORK UNTIL YOUR PERMIT HAS BEEN AUTHORISED BY THE RELEVANT MEMBER OF STAFF.


PRIMARY HAZARDS - Electric Shock / Arcing / Arc Flash / Fire / Trapping / Crushing / Entanglement / Amputation / Severing / contact with Hazardous Substances

Please answer the questions truthfully

  • Are you Qualified / Trained to undertake this work?

  • Are Caution / Danger Signs required?

  • Can a Temporary Guard be fitted, i.e. Mesh Guard / Polycarbonate - that allows vision but protects maintenance worker?

  • Does the Machine have an Engineering Mode in the PLC Program - that allows slow movements / jog mode/ safety pendant control / hold to run functions to be operated?

  • If Moving Parts are present can the Emergency Stop be accessed from the work position and is it functional?

  • Is all lose clothing / long hair etc secure to prevent contact with moving parts?

  • Are 1000V VDE Insulated Tools in Use? Must meet DIN EN 60900:2004

  • Has Lock Out Tag Out been undertaken, if appropriate? i.e. between tests / when equipment is left unattended.

  • Are you likely to come into contact with asbestos? If Yes, an Asbestos Permit to Work will be required.


  • Other Precautions Required to undertake the work safely:

  • Other Safety Equipment required to undertake the work safely:

AUTHORISATION & ACCEPTANCE - I confirm that I have verified the above information and ensured that the necessary precautions have been taken. It is safe to carry out the works as defined above and the permit has been explained to all workers involved. I accept responsibility for this work.

  • Person in Charge of Works

  • Company

  • Signature

  • Authorising Person


  • Permit Expires on


  • Name of Standby Rescuer (Live Running with Guards Removed)

  • Emergency Contact Number

  • Rescue Method to be deployed: Emergency Stop / Reverse Control / Remote Pendant

Live Running Testing Works are not permitted without a Standby Person trained in effecting a safe rescue if guards are removed.


I confirm that the work has been completed, checked by myself, guards have been refitted and interlocks reinstated and the area left in a safe and tidy condition.

  • Person in Charge (Print Name)

  • Person in Charge (Signature)

I have inspected the completed work, confirmed that guards have been refitted and interlocks have been reinstated in accordance with the manufacturers instructions. I hereby cancel this permit.

  • Authorised Person (Print Name)

  • Authorised Person (Signature)


  • Permit Cancelled

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