Permit to Work - Mechanical System Isolations

• 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

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

  Yes

  No

• Relevant and suitable written system of isolation available and reviewed?

  Yes

  No

• Works being undertaken at time of least risk and area cleared of unauthorised staff?

  Yes

  No

  N/A

• Access to work area restricted and barriers/warning notices in place where required?

  Yes

  No

  N/A

• Work area clear of trip hazards and obstructions?

  Yes

  No

  N/A

• Schedule of isolation, Risk Assessment/Method Statement attached to permit?

  Yes

  No

  N/A

• All personnel involved understand the local Emergency Procedures?

  Yes

  No

• Any other systems affected by the isolation/works identified and control measures in place?

  Yes

  No

• Landlord/Insurers and any other parties that may be affected informed of 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.