Permit To Work Certificate

• PTW [Number]

• Contractor Company

• Area of Work

• Valid From (Date + Time)

  Date

• Valid Until (Date + Time)

  Date

• Jigsaw Responsible Person

  Select Ian Glaves Tom Rushby Trevor Arthur Charlie Taphouse Josh Moore Paul Clarke Roger Butcher Dave Mason Robert Dodson Jo Quinn

  • Ian Glaves
  • Tom Rushby
  • Trevor Arthur
  • Charlie Taphouse
  • Josh Moore
  • Paul Clarke
  • Roger Butcher
  • Dave Mason
  • Robert Dodson
  • Jo Quinn

• Contractor Responsible Person

• Details of Work

• Is the scissor lift to be used (Full WAH Permit not needed)

  Yes

  No

• Do we have a copy of the contractors IPAF 3A certificate

  Yes

  No

Further Permits

• Are Further Permits Required

  Yes

  No

• Choose Required Permits From Dropdown List

  Select Hot Work Work at Height Confined Space Fragile Roof High Voltage Excavation

  • Hot Work
  • Work at Height
  • Confined Space
  • Fragile Roof
  • High Voltage
  • Excavation

• All Persons working at height have been trained and any relevant certification has been provided

  Yes

  No

• All tools will be secured with no potential of them falling from height

  Yes

  No

• What form of work at height will be used

  Select Cherry Picker or Articulated Boom Scaffold Tower Ladders / Step Ladders

  • Cherry Picker or Articulated Boom
  • Scaffold Tower
  • Ladders / Step Ladders

• Has the user Completed an IPAF 3c certified Training Course

  Yes

  No

• Has the certification been seen and a copy stored in the relevant H&S folder

  Yes

  No

• YOU WILL NOT BE ALLOWED TO DRIVE OR OPERATE A MEWP ON THIS SITE

• Is a safety harness required for this task

  Yes

  No

• The user is to inspect the harness and ensure it is in an acceptable condition

  Yes

  No

• PLEASE REPLACE THE HARNESS OR ASK YOUR HOST IF YOU CAN BORROW ONE OF JIGSAW FOODS HARNESS'S

• Has the user completed a PASMA certified training course

  Yes

  No

• Has the certification been seen and a copy stored in the relevant H&S folder

  Yes

  No

• The user is to ensure the scaffold is checked for defects, is built correctly and safely and the scafftag has been completed and correctly displayed (Blank Scafftags are supplied by our H&S manager in unit 1 - contact ext 3142)

  Yes

  No

• YOU WILL NOT BE ALLOWED TO ERRECT OR CERTIFY THE SCAFFOLD TOWER - ASK YOUR HOST TO ARRANGE FOR THE TOWER TO BE BUILT FOR YOU AND THE PASMA TRAINED PERSONNEL TO INSRUCT YOU ON THE SAFE USE OF THE TOWER

• Ladders have been checked, are in good condition and are appropriate for this task

  Yes

  No

• DO NOT USE THIS LADDER, YOUR HOST MAY BE ABLE TO ARRANGE FOR YOU TO USE A SET OF OUR ENGINEERS LADDERS

• A second person must be used to stabilise the ladder, this applies to all ladder types, is a second person available

  Yes

  No

• DO NOT ATTEMPT TO USE THE LADDER UNASSISTED, YOUR HOST MAY BE ABLE TO PROVIDE SOMEONE TO ASSIST YOU

• Have Risk assessments been carried out specifically for the work to be done

  Yes

  No

Further Information

• Are there RAMS for this Project ? If not and you are in any doubt whether they are needed contact H&S for advice

  Yes

  No

  N/A

• Discuss with the contractor how the project will be done and how you will mitigate any hazards to ALARP. Has this been Done

  Yes

  No

• Has the Contractor Induction Agreement been Received / Completed

  Yes

  No

• Are You willing to Sit the Induction now

  Yes

  No

• Please Leave site, do not start work !!

  Drawing

• Equipment to be isolated

  Yes

  No

• Electrical Lock off to be applied

  Yes

  No

• Compressed Air ,Liquid Pipeline, Gas, Fuel to be drained and cleaned

  Yes

  No

• Is nearby equipment safe for work to proceed

  Yes

  No

• Have other departments been informed where necessary

  Yes

  No

• Are barricades, hoarding or cordons required

  Yes

  No

• Are warning notices needed ? if yes they must be posted

  Yes

  No

• Is there adequate access, and Lighting

  Yes

  No

• Do contractors have required PPE, including specialist PPE, Minimum safety shoes and hi-viz vest.

  Yes

  No

• Are other permits live in the area

  Yes

  No

• Will the Jigsaw Representative be on site for periods when the contractor is on site.

  Yes

  No

• Name of supervising Jigsaw Employee

• Are all laws and regulations complied with

  Yes

  No

• Do you Require any Further advice from H&S Department

  Yes

  No

Jigsaw Foods Responsible Person sign as all information correct and sign over to contractor

• Jigsaw Foods Responsible Person Name / Signature

  Sign

• Contractor / Engineer Name / Signature

  Sign

Sign Off - Work complete and area left in a safe and tidy condition - Checked by Jigsaw Foods responsible person

• Jigsaw Foods Responsible Person Name / Signature

  Sign