Permit valid. From Date: Time: To Date: Time:

Site Induction complete

Green card sighted

SWMS have been received


Brief description of works

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

Hot Works

Energy isolations

Confined space

Working at heights

Working Area


Number of workers

Personal Protective Equipment

Is there any requirement for PPE

Does the worker have all required PPE to complete the works

Hot Works Requirements - to be completed by Key Services

CO2 fire extinguisher provided

Barricades, warning, signs & spark/flash screens provided

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

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

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

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

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

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

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

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

Smoke detectors must be isolated in the work area

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

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

Building Managment / Security
Energy Isolations

Has approval been given for the isolation

Testing equipment is in good working order

Locks and/or tags have been installed

Confined Space

Has the worker completed confined space training

Confined space permit completed.

Working at Heights

Has the worker completed working at heights training

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

Fall restraint system required

Fall restraint equipment is in good working order and in date

Completion of Work

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

Have all Isolations and alarms been reactivated

Signed Key Services
Signed Subcontractor
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.