Permit to Work (PTW)

• Conducted on

  Date

• Prepared by

• Location
  Address

Permit Board & Area Check

• Is the Permit board in good order?

  Yes

  No

  N/A

• Is the Permit board being used effectively?

  Good

  Fair

  Poor

  N/A

• Is there work being carried out which SHOULD have a Permit, but which is NOT on the Permit board?

  Pass

  Fail

  N/A

• Is there a completed Permit for this work?<br>(i.e. Though not displayed properly, the Permit system has been followed)<br>[Note: If not, stop the job. A Permit & Risk Assessment must be completed before continuing]

  Yes

  No

  N/A

Specific Permit Check

• Permit Number

• [Image of the Permit]

  Media

• Name of Individual Performing the Work

• Name of Individual Issuing the Permit

• Is the Permit Issuer Authorised to do so?

  Yes

  No

  N/A

• Is there a copy of the Permit both on the Board and at the Job Site?

  Yes

  No

  N/A

• Have all sections of the Permit been fully completed?

  Yes

  No

  N/A

• Is there a Risk Assessment for the job?<br>(Dynamic; RAMS; SOP; or other appropriate RA)

  Yes

  No

  N/A

• Is the work being carried out in accordance with the controls outlined in the Permit and the Risk Assessment?

  Safe

  At Risk

  N/A

• Feedback provided to the individual:

• Acceptance of Feedback

  Sign

• Feedback provided to the Shift Supervisor:

• Acceptance of Feedback

  Sign

• Feedback provided to the Process Manager:

• Acceptance of Feedback

  Sign