Title Page

  • Company/Entity doing the work

  • Location/Work Site
  • Conducted on

  • Prepared by

Permit Request

  • Work Activity Title

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

  • Start of Work

  • End of Work

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.

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

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

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

  • 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.

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

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


  • Full Name and Signature of Supervisor

Person Engaging Contractor/Worker Review

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.

  • 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.

  • 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.


  • Full Name and Signature of Person Engaging Contractor/Worker



  • 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.

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


  • Full Name and Signature of Permit to Work Authorized Person

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.