Permit to Work Template

• Company/Entity doing the work

• Location/Work Site
  Address

• Conducted on

  Date

• Prepared by

• Work Activity Title

• Specified high-risk work tasks covered to work by this permit

  Select Hot Work Confined Space Excavation Plant Isolation Work at Heights Live Electrical Maintenance Work Other

  • Hot Work
  • Confined Space
  • Excavation
  • Plant Isolation
  • Work at Heights
  • Live Electrical Maintenance Work
  • Other

• Start of Work

  Date

• End of Work

  Date

Permit Request (On-site supervisor of the contractor/workers who have been engaged to perform the work)

• This acknowledgement signifies a formal request to commence a work activity invoking one or more specified high-risk tasks. As the person requesting this permit, I hereby certify that

• I have developed and/or reviewed the Risk Assessment and required Control Form/s relevant to this work activity.

  Yes

  No

  N/A

• I have consulted with relevant people to ensure that controls are adequate.

  Yes

  No

  N/A

• I am competent to coordinate this work activity in accordance with the attached Risk Assessment and Control Form/s.

  Yes

  No

  N/A

• I shall undertake to implement all planned and necessary controls to ensure the health and safety of those completing or impacted by the activity.

  Yes

  No

  N/A

• I shall ensure that the persons required to carry out the work are advised of and understand the requirements of the Risk Assessment and Control Form/s, and the Permit To Work / Access Instructions in Section 4 below.

  Yes

  No

  N/A

• I shall monitor hazards and control methods throughout the work activity.

  Yes

  No

  N/A

• I am requesting this Permit to be reviewed, registered and numbered by the Permit to Work Authorised Person.

  Yes

  No

  N/A

Completion

• Full Name and Signature of Supervisor

  Sign

Person Engaging Contractor/Worker Review

• This sign off is to signify that the PBPL person who engaged the contractor/worker has reviewed all documentation and provided comments

• I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s and provided feedback to the contractor/workers.

  Yes

  No

  N/A

• I confirm as the person who engaged the contractor/worker, I will monitor the methods of work and the implementation of the proposed controls to ensure that standards for health and safety are being achieved throughout the works.

  Yes

  No

  N/A

• I have informed the relevant person/s for the area that the work is being performed in, the full scope of works to be completed by the contractor/workers and the processes developed for supervising and enforcing the works.

  Yes

  No

  N/A

Completion

• Full Name and Signature of Person Engaging Contractor/Worker

  Sign

Authorization

• This authorization signifes that the planning component of the work activity has been completed and that the work is authorized to commence in accordance with the risk assessment and required control forms. As the Permit to Work Authorized , i hereby certify:

• I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s.

  Yes

  No

  N/A

• I have registered this permit in the Permit To Work Register, allocated it a number and have written the number on all associated documents.

  Yes

  No

  N/A

Complete

• Full Name and Signature of Permit to Work Authorized Person

  Sign