Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
PERMIT TO WORK
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The purpose of this document is to ensure that only authorised personal are working in hazardous areas or carrying out work on Adaptable Training Partnerships (ATP) work sites. Additionally a thorough risk analysis is conducted and appropriate controls put in place before the work is carried out. This permit does not relieve the contractor and employees of their obligations in respect of compliance with other ATP OSHE standards.
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Contractor:
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Service Order Number:
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Name and Signature:
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The ATP Company Representative or nominee is responsible to ensure that this document is completed and all requirements are met.
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Employee:
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Work Order Number:
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Name and Signature:
Description of Work:
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Work Location:
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Contracting Company or Department:
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Start Date:
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Work Finish Date (Est):
DOCUMENT VERIFICATION: (any yes answers on this check list must have the appropriate permits or permission's attached to the Permit to work)
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Checklist:
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1.Does the Contractor have a Service Order for the work? ( Work must not proceed unless there is a service order for the work)
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2. The work scope is well defined and understood.
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3. A current Risk Assessment / JHA for the work has been conducted and approved. (If not conduct a JHA and get it approved).
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4. The fitness for work issues have been conducted for personal working under the permit.
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5. Is there a current "SWP" for this Job?
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6. Has a Change Management form been completed where required for the work covered under this "Permit to Work"
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7. Have the following permits been raised if required for the work covered under this "Permit to Work"?
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Confined Space Permit:
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Permit NO:
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Dig / Excavation Permit:
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Permit NO:
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Hot Works Permit:
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Permit NO:
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Isolation Permit:
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Permit NO;
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Work at Heights Permit:
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Permit NO:
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High Voltage (Vicinity) Permit:
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Permit NO:
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Rail Access Road Permit:
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Permit NO:
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8. Is any electrical work to be performed:
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A: Has everyone performing electrical work completed an Electrical Workers Competency?
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B: Is intent to commence Electrical Install form and/or Electrical Log required?
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9. Is any work to be performed by or on registered and/or classified machinery ?
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10. Are all tools and electrical equipment to be used on site in a safe condition ?
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11. Have all required vehicles been inspected & vehicle specific Risk Assessment been completed ?
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12. Is any work to take place within 3 meters of a Rail Track ?
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13. Does any work to be performed under this Permit to Work require "hand rail or grid mesh removal ?
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14. Have all Chemicals coming to site been approved and have the WSDS/SDS ?
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15. Is adequate supervision being provided for the job ?
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16. Is Sub-contractor use agreed by Company Representative ? (If "YES", the sub-contractor must be included in the principle contractors "Permit To Work" or the company rep must issue a new "Permit to Work" to the sub-contractor).
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17. Have all persons working under this permit completed the required inductions ?
People Covered Under This Permit.
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Name
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Licenses / Qualifications Verified
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Comments:
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People Covered under this Permit
Person
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Name & Sign:
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Date & Time:
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Authorised By:
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Name & Sign:
PERMIT TO WORK: Sign on:
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Contracting Company Supervisor: Name & Sign:
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Contact NO:
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Company Represantitive: Name & Sign:
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Contact No:
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Authorising Person: Name & SIGN:
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Contact NO:
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Emergency Contact:
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Contact NO:
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This Permit is Valid from:
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Time and Date:
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This permit is Valid to:
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Time and Date:
B
Permit Review History
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* This Permit MUST BE REVIEWED (By Company Rep or Supervisiour) each shift and reissued if a change in conditions or work scope has occured.
* A copy of the completed "Permit to Work" MUST be kept at the worksite until the work is completed.
* If transferring the permit, the initial permit holder must ensure that all relevant information/documentation is provided to the new permit holder>
* The "Permit to Work" is valid for a Maximum of 30 days from date of issue. -
Reviewer Name: Company Rep or Supervisiour.
Person
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Name & Sign:
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Has the work scope or conditions changed? (if so a new Permit must be issued)
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Take 5 or JHA completed?
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Date & Time:
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SHIFT:
Permit Transfer Details:
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New Permit Holder
Person
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Name & Sign:
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Date & Time From:
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Date & Time TO:
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Additional Information/Comments:
