Permit to Work

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General

• Is the work scope clearly defined?

  Yes

  No

  N/A

• Has the worksite/location been correctly identified?

  Yes

  No

  N/A

• Has the equipment worked on been correctly identified?

  Yes

  No

  N/A

• Has the scope of the work been correctly set and is the work within scope?

  Yes

  No

  N/A

• Has the person doing the work been inducted?

  Yes

  No

  N/A

Permit Authorisation

• Has task analysis been completed or attached?

  Yes

  No

  N/A

Special Precautions

• Is the correct type of certificate being used?

  Yes

  No

  N/A

• Are there adequate precautions /controls for tasks (including isolations)?

  Yes

  No

  N/A

• Are the necessary procedures and SOP's identified for reference and appended to the permit?

  Yes

  No

  N/A

• Are the correct isolations appropriate and in place for the job?

  Yes

  No

  N/A

Worksite

• Has the receiver fully briefed work party?

  Yes

  No

  N/A

• Is the permit available and visible at the site of work?

  Yes

  No

  N/A

• Is the work being carried out at the specified location?

  Yes

  No

  N/A

• Are the hazard controls being followed?

  Yes

  No

  N/A

• Is equipment in good order?

  Yes

  No

  N/A

• Is equipment appropriate to the job?

  Yes

  No

  N/A