Permit to work on / test* electrically isolated equipment

• Site conducted

  Select

• Permit Number:

• Associated PTW Number:

• Associated Permits

• Work specified in the Permit is conditional on all contractors having read, understood and signed the Integral Induction Pack.

• Company Name:

• Competent person in charge:

• Other personnel engaged in the works:

When

• From:

  Date

• Until:

  Date

Where

• Description of works:

• Comments / Special conditions:

Safety precautions:

• Disconnection – State isolation point(s), whether or not isolator(s) have been padlocked off, fuses drawn etc.

• Notification – State how users of the circuits and other contractors have been notified

• Warning notices and access control – State where caution / danger notices have been posted, and if appropriate, how work area has been fenced off

• Prove apparatus is dead – State what test(s) have been made, where and with what instruments

• Earthing – State where apparatus has been earthed and, for testing which earths may be removed

• Safety locks fitted – Specify

  Yes

  No

  N/A

• Comments:

• Other precautions – Specify additional requirements for special circumstances such as adverse environmental conditions

Approvals:

• Approved By:

• Signature:

  Sign

• Date:

  Date

Authorisation:

• Authorisation: I hereby declare that the above safety precautions have been taken and made known to the Competent Person in charge of the work. I consider that the apparatus specified above is safe to Work on / Test*.

• Issued By:

• Signature:

  Sign

• Date:

  Date

Acceptance:

• Acceptance: I acknowledge receipt of this Permit and understand the safety precautions described above. I have witnessed the isolations made and the circuit / system proved Dead. Neither I nor the personnel under my control will Work on / Test* any other electrically dangerous apparatus. I will return this Permit to the Authorised Person when the Work / Test* is complete. In the event of an emergency I will cease the work safely and comply with the Site emergency procedures. Work will only recommence when a new risk assessment has been done and a new permit issued.

• Accepted By:

• Signature:

• Date

  Date

Clearance:

• Clearance: I herby declare that the Work / Test* detailed above has been completed / stopped*, earths removed and personnel and equipment withdrawn. The apparatus and location are now in a safe condition.

• Returned By:

• Signature:

• Date:

Closure:

• Closure: I hereby declare this Permit closed. The original copy of the Permit has been returned to me by the Competent Person. I have inspected the Work / Test* location and I am satisfied that the apparatus detailed above may be reconnected for service.

• Closed By:

• Signature:

  Sign

• Date:

  Date