Permit to Work - Confined Spaces

• Site conducted

  Select

• Document No.

All accidents are avoidable. You have a responsibility to safeguard yourself and others who may be affected by your actions. No work must take place until this Permit has been completed in full and signed by an Authorised Person.

Section1: Site and Location

• Site/Location

• Contractor

• Brief description of work

• Conducted on

  Date

• Prepared by

• Names of Engineers

Section 2: Precautions and Control Measures

• Area isolated from all necessary sources of liquids, gases and free flowing solids?

  Yes

  No

• All personnel are suitably competent and trained to an acceptable standard in accordance with regulations?

  Yes

  No

  N/A

• Personal Protective Equipment (PPE) and Respiratory Protective Equipment (RPE) suitable for task?

  Yes

  No

  N/A

• Automatic air monitoring & alarm in place?

  Yes

  No

  N/A

• Personnel on site are sufficient and capable of carrying out the works safely?

  Yes

  No

  N/A

• Emergency rescue team in place and is sufficient and capable of effecting a rescue?

  Yes

  No

• Mechanical ventilation identified in Method Statement in place, suitable and tested?

  Yes

  No

• Atmospheric tests conducted and acceptable? (copy must be attached to the permit)

  Yes

  No

• Risk Assessment/Method Statement attached to permit? (including emergency rescue plan)

  Yes

  No

• Landlord representative and any other parties that may be affected informed of the works?

  Yes

  No

If the answer to any of the applicable questions is 'no' then you must not authorise the permit, but take corrective actions. If you are unsure about any aspect then you should not authorise the permit and seek further advice/guidance.

• Additional information on any of the above or any relevant issues:

Section 3: Authorisation of Permit

I declare that the above control measures are in place and communicated to the Competent Person in charge of the work

• Authorised Person:

  Sign

• Mobile Number:

• Valid From:

  Date

• Valid To:

  Date

Section 4: Acceptance of Permit by Competent Person in Charge

I acknowledge receipt of this permit and understand the safety precautions described above. I will adhere to the Method Statement and neither I, nor any person under my control will work on any other equipment. I will return this Permit to the Approved Person.

• Competent Person:

  Sign

• Mobile number:

Section 5: Time Extension (can only be granted by the Approved Person who issued the Permit)

• Authorised Person:

  Sign

• To:

  Date

Section 6: Completion of Works

I declare that the work detailed in section 1 has been completed or that no further work will take place until a new Permit is issued. The work area has been left safe, clean and tidy and equipment is safe to return to service unless otherwise stated.

• Competent Person:

  Sign

• Time/Date:

  Date

Section 7: Permit Closure

• Authorised Person:

  Sign

• Date/Time

  Date

Once the Permit has been closed, no further work activity can be undertaken and no return to high risk area is permitted.