Title Page

  • Location / Site

  • Prepared by

  • Conducted on

Permits / Isolation's

  • Permit is current - Generally valid for 1 shift only or the task duration

  • Permit and SWMS displayed at work location.

  • Permit requirements understood by relevant personnel.

  • Personnel complying with Permit procedure requirements.

  • All relevant personnel have signed the Permit

  • Isolations in place and verified.

  • Positive verification of zero energy.

  • SWMS is current and specific to the tasks performed.

  • Personal Danger Tags correctly filled out and in place

  • Permit close out requirements are being complied with.

  • Further Findings:


  • Name:

  • Select date

  • Signature:

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.