Title Page
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Site conducted
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Permit No.:
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Work request No:
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Associated Permits:
Who is carrying out the works
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Company Name?
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Competent person in charge:
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Other personnel engaged in the works:
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When will the works be carried out?
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From:
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Until:
Description of Works
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Where
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Description of Works
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Comments / Special Conditions?
Mandatory Safety Requirements
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The access equipment is suitable for the work location and the height to be worked at?
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Suspend permit and do not proceed further.
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Access equipment has been checked / examined by a competent person?
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Suspend permit and do not proceed further.
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Access equipment carries a current, valid certificate where appropriate?
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Suspend permit and do not proceed further.
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Fall-arrest equipment has been checked / examined by a competent person?
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Suspend permit and do not proceed further.
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Passive edge protection equipment has been checked / examined and put in place by a competent person?
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Suspend permit and do not proceed further.
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Adequate access and personal protection equipment is provided?
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Suspend permit and do not proceed further.
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Barriers to prevent unauthorised access to the work area have been put in place?
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Suspend permit and do not proceed further.
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The status of overhead services has been ascertained?
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Suspend permit and do not proceed further.
Approvals
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Approved by:
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Signature:
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Date:
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Authorisation: I confirm that I have personally checked that the Safety precautions above are in place and consider it safe to carry out this work.
Issued
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Issued By:
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Signature:
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Date:
Acceptance
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I accept responsibility for the work and personnel stated and agree to implement safe working procedures. I understand the hazards of this work and the precautions to be taken. These have been fully explained to the operatives carrying out this work and I consider them to be adequately trained and competent to use the equipment and to do the work safely. In the event of an emergency I will cease the work safely and comply with the Site emergency procedures. Work will only recommence when a new risk assessment has been done and a new permit issued. I will return my copy of this permit to the authorised person when this work has been safely completed.
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Accepted By:
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Signature:
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Date:
Clearance
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Clearance: I confirm that personnel and equipment have been withdrawn. The work has* / has not* been completed and uncompleted work will not restart until a new Permit is issued. (*Delete as applicable). The location has been restored to a safe and orderly condition. I have returned my copy of this Permit to the authorised person.
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Returned By:
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Signature:
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Date:
Closure
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I accept that the work has been safely completed. This permit is closed and invalid.
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Closed By:
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Signature:
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Date:
