Title Page
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Document No.
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PERMIT DESCRIPTION
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Client / Site
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Conducted on
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Permit supervisor
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Permit authoriser
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Location
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Permit supervisor has inspected the work area
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Permit supervisor has reviewed the Job Safety Analysis with the workers and is satisfied.
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If the work is a modification or within a project, has it been approved?
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Is all portable electrical equipment free of defects and do they have in date electrical test tags?
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Permit supervisor has inspected all Other equipment and it is in acceptable condition?
Personal Protective Equipment
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Safety glasses
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Safety boots
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Long sleeves and pants
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Goggles
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Face shield
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Splash apron
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Nitrile gloves
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Double layer gloves
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Leather gloves
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Chemical suit
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Chemical boots
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Cutting gloves
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Hard hat
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Sun protection
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Dust suit
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P2 mask
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Respirator (cartridge)
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Respirator (full face air supplied)
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Safety harness
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Hearing protection
Hot work
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Hot work
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Has the work area been cleared of combustibles
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Has all stored energy sources been released
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Is the work area near or on equipment that contains, or could contain explosives or flammable material
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Is the hot work zone isolated/barricaded to prevent unauthorised access
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Is ventilation adequate?
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Has fire equipment been checked and located in close proximity to hot work?
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Are spark and flash screens in place?
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Is a fire watch required?
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Please enter name of fire watcher
Chemical
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Chemicals
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Will chemicals be used
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Are the chemicals on the approved chemical list (ACL)
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Have the chemicals been reviewed by EHS and given temporary approval?
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Do the workers have MSDS for all chemicals they may be exposed to?
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Have the chemical risks been reviewed by the workers?
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Is there ready access to face wash and safety shower?
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Required PPE has been inspected
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PPE training has been completed
Working at heights
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WORKING AT HEIGHTS (anything over 1.2m)
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Is the work close to the edge?
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Is falling from height a risk?
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Is there a risk of falling objects
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Weather risk: high wind, rain
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Moving vehicles/ impact risk
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Unstable/uneven ground
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Are u working on a brittle or fragile surface?
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Electrical hazards?
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Sun exposure?
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Extreme temperatures?
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Light levels?
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Fall protection method
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Move equipment to ground level
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Permanent railing
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Scaffolding
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Elevated work platform
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Forklift and man cage
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Fixed or tied off ladder
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Fall restraint e.g guidelines
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Fall arrest e.g inertia reels and harness, nets.
LOTO
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Does the work require isolation or release of stored energy?
Permit sign on and authorisation
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As permit supervisor I have read the permit and understand the hazards and controls. I undertake to follow the requirements of this permit. I will immediately stop work and freeze permit if any changes need to be made to the work plan. Permit supervisor sign on.
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Additional signees
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I have read the permit and had the hazards and controls explained to me. I undertake to follow the requirements of this permit. I will immediately stop work and notify the permit issuer if any changes need to be made to the work plan.
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I have read the permit and had the hazards and controls explained to me. I undertake to follow the requirements of this permit. I will immediately stop work and notify the permit issuer if any changes need to be made to the work plan.
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I have read the permit and had the hazards and controls explained to me. I undertake to follow the requirements of this permit. I will immediately stop work and notify the permit issuer if any changes need to be made to the work plan.
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I have read the permit and had the hazards and controls explained to me. I undertake to follow the requirements of this permit. I will immediately stop work and notify the permit issuer if any changes need to be made to the work plan.
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I have read the permit and had the hazards and controls explained to me. I undertake to follow the requirements of this permit. I will immediately stop work and notify the permit issuer if any changes need to be made to the work plan.
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License and card record (if necessary)
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Permit valid from
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Permit expires at
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Permit authoriser is satisfied with job description
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Permit authoriser is satisfied with job safety analysis
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I authorise the recipients to complete the work as in the JSA, LOTO procedure and this permit.I have read the permit and had the hazards and controls explained to me.
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Permit authoriser name:
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Permit authoriser signature:
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Date:
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Time:
