Permit To Work

• Site conducted

  Select

• Permit Number:

• Permit Type - Permit to Work

• Concept Work Request Ref:

• Associated High Risk Permits:

  Yes

  No

• High Risk Permit type?

• No High Risk Permits Required.

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

• Company Name?

• Competent person in charge?

• Other personnel engaged in the works?

• Permit From:

  Date

• Permit Open Until:

  Date

Description Of Works

• Where will the works take place?

• Description of works.

• Why are the works being carried out?

• Has RAMS been submitted by the contractor and approved by Integral?

  Yes

  No

• RAMS viewed and approved by:

• I confirm that RAMS have been submitted and have been approved by a competent person before this permit is authorised.

• Non Intrusive works only, no requirement for RAMS.

High Risk Permits

• Please select the following High Risk Permits if required.

• Hot Works Permit

  Yes

  No

• Please complete a Hot Works Permit

• Working At Height

  Yes

  No

• Please complete a Working At Height Permit

• Confined Spaces

  Yes

  No

• Please complete a Confined Spaces Permit

• Work On Isolated Equipment

  Yes

  No

• Please complete a Work On Isolated Equipment Permit

• Work On Live Equipment

  Yes

  No

• Please complete a Work On Live Equipment Permit

Approvals

• Approved By

• Signature:

  Sign

• Date:

  Date

• Acceptance: I accept responsibility for the work / personnel stated and agree to implement safe working procedures. I understand the Hazards of this work and the precautions to be taken. These have been fully explained to the operatives carrying out this work and I consider them to be adequately trained and competent. Work will only be undertaken on the job / equipment specified. I will return my copy of this permit to the authorised person when the work has been safely completed. 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 carried out and a new permit issued.

• Accepted By

• Signature:

Declaration By Personnel

• I confirm that I have been briefed about the task(s) to be undertaken under this permit. I understand and accept the Method to be used, the Hazards involved, the Control measures and Safety precautions to be taken and the residual risks.

• I have been provided with sufficient and appropriate PPE , Safety equipment and have been trained in its use.

• Emergency procedures have been explained to me and I understand what to do in an emergency.

• NB. If you are in any doubt regarding any of the safety issues in connection with this job, DO NOT SIGN THIS FORM. Consult your Supervisor, Safety Representative or Safety Officer.

• Signature:

• Clearance: I confirm that personnel and equipment have been withdrawn. The work *has / has not* been completed and uncompleted work will not restart until a new Permit is issued. (*Delete as applicable). The location has been restored to a safe and orderly condition. I have returned my copy of this permit to the authorised person.

• Returned By:

• Signature:

• Date & Time:

  Date

Permit Closure

• I accept that the work has been safely completed. This permit is now closed and invalid.

• Closed By:

• Signature

  Sign

• Date & Time

  Date

COMPLETION OF WORKS VERIFICATION

• Were the works completed?

  Yes

  No

• Why were the works not completed?

• Were the works completed safely?

  Yes

  No

  N/A

• Why were the works deemed unsafe

• Were any penetrations or changes to infrastructure made during works that will compromise Fire Compartmentalisation?

  Yes

  No

• Please detail measures and materials used to carry out fire stopping.

• Fire Sleeves

• Please provide details where the Fire Sleeves were installed;

• Fire Collars

• Please provide details where the Fire Collars were installed;

• Fire Covers

• Please provide details where the Fire Covers were installed;

• Fire Sealants and Gap Fillers

• Please provide details where the Fire Sealant and /or Gap fillers were installed;

Unacceptable Risks?

• Risk to engineers?

  Safe

  At Risk

  N/A

• What was the unacceptable risk?

• Risk to the infrastructure?

  Safe

  At Risk

  N/A

• What was the unacceptable risk?

• Risk to the business?

  Safe

  At Risk

  N/A

• What was the unacceptable risk?

• Risk to security?

  Safe

  At Risk

  N/A

• What was the unacceptable risk?

Non-compliance by contractor?

• Wrong personnel working?

  Yes

  No

• Comment

• Working outside the duration of the permit?

  Yes

  No

• Comment

• Working in the wrong place?

  Yes

  No

• Comment

• Working outside the scope of the permit?

  Yes

  No

• Comment

• Not adhering to the Method Statement

  Yes

  No

• Comment

Security Checks

• Permit(s) returned

  Yes

  No

• Permit(s) closed

  Yes

  No

• Received By:

• Signed:

  Sign

• Date:

  Date

• Additional observations / comments