• Permit supervisor has inspected the work area

  • Permit supervisor has reviewed the Job Safety Analysis with the workers and is satisfied.

  • If the work is a modification or within a project, has it been approved?

  • Is all portable electrical equipment free of defects and do they have in date electrical test tags?

  • Permit supervisor has inspected all Other equipment and it is in acceptable condition?

Personal Protective Equipment

  • Safety glasses

  • Safety boots

  • Long sleeves and pants

  • Goggles

  • Face shield

  • Splash apron

  • Nitrile gloves

  • Double layer gloves

  • Leather gloves

  • Chemical suit

  • Chemical boots

  • Cutting gloves

  • Hard hat

  • Sun protection

  • Dust suit

  • P2 mask

  • Respirator (cartridge)

  • Respirator (full face air supplied)

  • Safety harness

  • Hearing protection

Hot work

  • Hot work

  • Has the work area been cleared of combustibles

  • Has all stored energy sources been released

  • Is the work area near or on equipment that contains, or could contain explosives or flammable material

  • Is the hot work zone isolated/barricaded to prevent unauthorised access

  • Is ventilation adequate?

  • Has fire equipment been checked and located in close proximity to hot work?

  • Are spark and flash screens in place?

  • Is a fire watch required?

  • Please enter name of fire watcher

Chemical

  • Chemicals

  • Will chemicals be used

  • Are the chemicals on the approved chemical list (ACL)

  • Have the chemicals been reviewed by EHS and given temporary approval?

  • Do the workers have MSDS for all chemicals they may be exposed to?

  • Have the chemical risks been reviewed by the workers?

  • Is there ready access to face wash and safety shower?

  • Required PPE has been inspected

  • PPE training has been completed

Working at heights

  • WORKING AT HEIGHTS (anything over 1.2m)

  • Is the work close to the edge?

  • Is falling from height a risk?

  • Is there a risk of falling objects

  • Weather risk: high wind, rain

  • Moving vehicles/ impact risk

  • Unstable/uneven ground

  • Are u working on a brittle or fragile surface?

  • Electrical hazards?

  • Sun exposure?

  • Extreme temperatures?

  • Light levels?

  • Fall protection method

  • Move equipment to ground level

  • Permanent railing

  • Scaffolding

  • Elevated work platform

  • Forklift and man cage

  • Fixed or tied off ladder

  • Fall restraint e.g guidelines

  • Fall arrest e.g inertia reels and harness, nets.

LOTO

  • Does the work require isolation or release of stored energy?

Permit sign on and authorisation

  • 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.

  • Additional signees

  • 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.

  • 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.

  • 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.

  • 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.

  • 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.

  • License and card record (if necessary)

  • Permit valid from

  • Permit expires at

  • Permit authoriser is satisfied with job description

  • Permit authoriser is satisfied with job safety analysis

  • 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.

  • Permit authoriser name:

  • Permit authoriser signature:

  • Date:

  • Time:

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