Permit to work - duplicate

• Permit No.

• Contracting Company

• Responsible person

• Responsible persons mobile number

• Additional Personal

• Location
  Address

• Permit Start

  Date

• Activities To Be Undertaken On Site?

  Select Confined Space Electrical Hot Works Pressure Systems Lifting Equipment Working At Height Excavations Lone working Use of MEWPS

  • Confined Space
  • Electrical
  • Hot Works
  • Pressure Systems
  • Lifting Equipment
  • Working At Height
  • Excavations
  • Lone working
  • Use of MEWPS

• Job details

• PPE Requirements

• Please state what PPE is required?

  Select Safety boots Hard hats Safety Gloves Hi- Vis Clothing Hearing Protection Harness Respirator Eye Protection Life jackets

  • Safety boots
  • Hard hats
  • Safety Gloves
  • Hi- Vis Clothing
  • Hearing Protection
  • Harness
  • Respirator
  • Eye Protection
  • Life jackets

• Permit Estimated End

  Date

• Prepared by

• Additional comments

General details

• Is there a risk assessment and method statement/SSOW available for the works

  Yes

  No

• State Reason

• Is this answer

  Acceptable

  Not Acceptable

• Permit application rejected

• Will this work encroach upon any other work, for which a permit to work will be/has been issued?

  Yes

  No

  N/A

• Has consultation and precautions taken place

  Yes

  No

• State reason why

Hazards and Precautions to be taken

• Is Working At Height Required

  Yes

  No

• Can Working At Height Be Avoided

  Yes

  No

• Is There A Danger Of Falling

  Yes

  No

• Is There A Risk Of Falling Objects

  Yes

  No

• Is There A Danger To Other Not Working

  Yes

  No

• Have Tools & Equipment Been Inspected

  Yes

  No

• Is Work At Height Of Short Duration

  Yes

  No

• What Form Of Equipment Is To Be Used Whilst Working At Height

  MEWP/SISSOR LIFT

  LADDERS/STEP LADDERS

  SCAFFOLDING

  OTHER, PLEASE STATE

• Please State

• Is A Safety Hardness Required

  Yes

  No

• Has This Been Inspected?

  Yes

  No

• Are There Any Other Factors That Could Effect The Safety Of The Workers

• Is Electrical Works Required

  Yes

  No

• Can Live Work Be Avoided

  Yes

  No

• Will Isolation & Check Be Applied Before Start Of Works

  Yes

  No

• Will All Procedures Comply With The Electricity At Works Regulations

  Yes

  No

• Have You Got Adequate Protection Against Shocks And Flashovers

  Yes

  No

• Is There Sufficient Light To Work Safely

  Yes

  No

• Will The Isolator Be Locked Of And Tagged

  Yes

  No

• Please Provide Details Of LOTO

• Additional comments

Authorization and Acceptance

• I confirm that I have accepted responsibility for the works to be carried out, and will ensure all health and safety and hygiene instructions are complied with. Competent authorised persons will carry out the works in accordance with the risk assessment & method statement

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• I am competent to authorise this permit, subject to the conditions indicated the works may proceed

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date

Hand Back and Cancellation

• I certify that

• undefined

  Select The work has been completed Equipment has been removed Plant and machinery has safely been returned to service Disable fire protection zones have been reinstated

  • The work has been completed
  • Equipment has been removed
  • Plant and machinery has safely been returned to service
  • Disable fire protection zones have been reinstated

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date