Permit to Work SENSUS

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General

• Permit to Work date.

  Date

• Time permitted to start.

  Date

• Permit end date.

  Date

• Time works must cease.

  Date

• Site Induction complete

  Yes

  No

  N/A

• Safety induction card sighted

  Yes

  No

  N/A

• Photograph of safety card.

  Media

• SWMS have been received

  Yes

  No

  N/A

• Company/ individual requesting permit.

• Brief description of works

Work Permits - are any of the following work permits required?

• Hot Works

  Yes

  No

  Not Applicable

• Energy isolations

  Yes

  No

  Not Applicable

• Confined space

  Yes

  No

  Not Applicable

• Working at heights

  Yes

  No

  Not Applicable

Working Area

• Location

• Number of workers

Personal Protective Equipment

• Is there any requirement for PPE

  Yes

  No

  Not Applicable

• Does the worker have all required PPE to complete the works

  Yes

  No

  N/A

Hot Works Requirements - to be completed by Key Services

• CO2 fire extinguisher provided

  Yes

  No

  N/A

• Barricades, warning, signs & spark/flash screens provided

  Yes

  No

  N/A

• Work area, trenches, pits clear of flammable liquids, gases or vapours

  Yes

  No

  N/A

• Combustibles located within 15m removed or protected with non combustible curtains, metal guards or flame proof covers

  Yes

  No

  N/A

• All floor and wall openings within 15m have been covered to prevent the transmission of sparks

  Yes

  No

  N/A

• The work area and all adjacent areas have been inspected at the completion of works ensuring no fire conditions were present

  Yes

  No

  N/A

• The hot work area and any adjoining areas must be patrolled from the start of the work until 60 minutes after the work is completed

  Yes

  No

  N/A

• The work area has been cleaned and clear to prevent any trip or slip hazards

  Yes

  No

  N/A

Hot Works Requirements - to be completed by Building Managment / Security

• Fire Sprinklers and / or thermal detectors must be confirmed operational where installed

  Yes

  No

  N/A

• Smoke detectors must be isolated in the work area

  Yes

  No

  N/A

• The work area and all adjacent areas where sparks may spread were inspected after works complete, ensuring no fire conditions were present

  Yes

  No

  N/A

• De-isolation of the smoke detectors within hot works area within 40 mins of the completion of the works

  Yes

  No

  N/A

• Building Managment / Security

  Sign

Energy Isolations

• Has approval been given for the isolation

  Yes

  No

  N/A

• Testing equipment is in good working order

  Yes

  No

  N/A

• Locks and/or tags have been installed

  Yes

  No

  N/A

Confined Space

• Has the worker completed confined space training

  Yes

  No

  N/A

• Confined space permit completed.

  Yes

  No

  N/A

Working at Heights

• Has the worker completed working at heights training

  Yes

  No

  N/A

• Has the worker been trained in the use of fall restraint equipment

  Yes

  No

  N/A

• Fall restraint system required

  Yes

  No

  Not Applicable

• Fall restraint equipment is in good working order and in date

  Yes

  No

  N/A

Completion of Work

• Has the work area been restored to normal safety / housekeeping requirements

  Yes

  No

  N/A

• Have all Isolations and alarms been reactivated

  Yes

  No

  N/A

• Signed Site Supervisor.

  Sign

• Signed Subcontractor

  Sign