Title Page

  • Site conducted

  • Permit number

  • Location
  • Site emergency phone numbers

  • Conducted on

  • Prepared by

  • Contractor

  • Contractor Supervisor

  • Name(s) of the operative(s) - only named operatives will be allowed access

  • Contact(s) of the operatives(s) - mobile phone number(s)

  • Access Fobs and access keys requested

  • Location of work


  • Description of work to be carried out

  • Can the work in the confined space be carried out from outside the confined space? (If yes prohibit entry and undertake work from outside.<br>Confirm that work in the confined space cannot be avoided? <br>(there should be sufficient explanation why)

Specific Safety requirements before commencing work

Physical Measures/actions

  • Isolate the area to prevent ingress of harmful substances such as dust and fumes

  • Sludge/deposits removed, where applicable?

  • Space ventilated prior to entry?

  • Plant/valves etc. isolated and locked off as necessary?

  • Clean or purge any tank/vessel before work is undertaken within if necessary

  • Gas test OK prior to entry?

  • Continue to monitor the atmosphere for flammable and or toxic vapours and to ensure there is sufficient oxygen

Management Control

  • Risk assessment conducted identifying the nature of the confined space hazard, any introduced hazards and control measures required?

  • Safe system of work/method statement documented, and workers trained in the findings?

  • Workers appropriately qualified for type of confined space entry and for confined space rescue as applicable? Certificates provided – identities checked?

  • Are sufficient workers allocated to the job? N.B. Lone working not permitted. For a traverse, minimum of 2 persons to enter, plus top man.

  • Competent supervision provided?

  • Rescue plan in place, equipment readily to hand and workers trained?

  • If the rescue plan involves rescuers entering the space, are there at least two staff who are equipped with BA and trained to use it?

  • Means of communication readily available? N.B. Check signal

  • All persons fit to enter?


  • All equipment available as per method statement and within calibration date where applicable including as applicable: winch, tripod, gas monitor, harnesses, PPE, first aid, communications, escape sets/breathing apparatus (BA), intrinsically safe electrical equipment?

  • Is the Contractor approved through Permissions Process and documentation approved?

Safety Confirmation

  • Confirmation that there are no reasonably practicable alternatives to this work to make it safer?

  • Permit Starts

  • Permit Ends

Acknowledgement of Permit to Work Conditions

  • The holder of the permit is the employee of a company that has been appointed in accordance with Living by Lendlease procedures or is an authorised employee of Living by Lendlease

  • The holder of the permit complies with the restrictions and conditions detailed in the permit and attached to it (where applicable)

  • The holder of the permit complies fully with all the requirements of the documents HSE Requirements for Contractors, Environmental Site Rules for Contractors, Health and Safety Policy, Environmental Policy

  • The holder of the permit ensures that he/she/they (or his/hers/their employees as appropriate) are provided with means of communication in the event of an emergency whilst on this site

  • Any change in the scope of work or failure to follow conditions identified in this Permit will automatically invalidate the permit. All proposed changes must be notified to the person who issued the permit (Authorised Person)

  • The Permit cannot be transferred between contractors or shifts. In such cases, a new Permit will be issued.

  • In an emergency, the permit holder should follow site emergency procedures. In such cases, the permit will automatically become void and a new permit will need to be issued before work can start again.

  • Where work is suspended for any reason, the permit will automatically become void and a new permit will be needed before work can start again.

  • I understand the scope of works, Living by Lendlease Conditions of issue and precautions agreed to be undertaken.

  • Permit holder signature

  • Contractor

Extension of Permit to Work

  • Time Extension

  • Start

  • End

  • Reason for Extension

  • Authorised person signature

  • Contractor Supervisor signature


  • The area has been left in a safe condition, equipment and work materials have been removed.

  • Contractor Supervisor signature

  • Date & Time

The Permit is now cancelled

  • Authorised person signature

  • Date & Time


  • Were any poor health and safety practices identified?

  • Did you have to prohibit work or give any official warnings?

  • Was work being carried out in accordance with the Permit to Work?

  • Was work being carried out in accordance with risk assessments and method statements?

  • Did contractors have copies of the Permit to Work?

  • Was the contractor complying with the site rules?

  • Was the work area suitably protected i.e. fenced / barriered and adequate safety signage provided?

  • Was housekeeping acceptable?

  • Completed by:

  • Position:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.