PfPL Test Valley Permit to work

• Conducted on

  Date

• Site

• Company: Places for People Leisure Management

• Prepared by:

• Type of permit:

  Select General Hot works Electrical Work at Height Confined Spaces

  • General
  • Hot works
  • Electrical
  • Work at Height
  • Confined Spaces

• Date/Time from:

  Date

• Date/Time until:

  Date

• Description/Type of works:

• Area of the building affected

Name of contractor/employee:

• Name of contractor/employee:

• Company name:

• Position:

• H&S Policy attached

  Yes

  No

  N/A

• Environmental Policy attached

  Yes

  No

  N/A

• Risk Assessment attached

  Yes

  No

• Method Statement attached

  Yes

  No

• COSHH Information attached

  Yes

  No

  N/A

• Review H&S file (Asbestos etc)

  Yes

  No

  N/A

General

• Inform whoever maybe affected by the work

  Yes

  No

  N/A

• Communication

  Yes

  No

  N/A

• Additional access

  Yes

  No

  N/A

• Ventilation

  Yes

  No

  N/A

• Lighting levels

  Yes

  No

  N/A

• Warning signage

  Yes

  No

  N/A

• Secure the area from the public

  Yes

  No

  N/A

• Site tour & safety review

  Yes

  No

  N/A

PPE

• Goggles

  Yes

  No

  N/A

• Face Shield

  Yes

  No

  N/A

• Ear Defenders

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Protective Suit

  Yes

  No

  N/A

• Face mask

  Yes

  No

  N/A

• Hard Hat

  Yes

  No

  N/A

• Safety Harness

  Yes

  No

  N/A

• Safety Footwear

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

Special precautions

• Are there any additional special works being carried out?

  Select Work at Height Confined Spaces Hot Works No other special works

  • Work at Height
  • Confined Spaces
  • Hot Works
  • No other special works

Work at Height

• Safe means of access/exit/rescue

  Yes

  N/A

• Ladders inspected

  Yes

  N/A

• Weather conditions considered (external work only)

  Yes

  N/A

• Netting & kicker boards fitted

  Yes

  N/A

• Scaffolding erected by certificated person

  Yes

  N/A

• Personnel trained in use of safety harness

  Yes

  N/A

• Mobile platforms operated by a correct IPAF certificated person

  Yes

  N/A

• Alloy towers erected by a PASMA certificated person

  Yes

  N/A

Confined Spaces

• Safe means of access/exit/rescue

  Yes

  No

• Ladders inspected

  Yes

  N/A

• Weather considered (external)

  Yes

  N/A

• Gas monitoring equipment within date (if required)

  Yes

  N/A

• Personnel trained in use of safety harness

  Yes

  N/A

• Breathing apparatus required

  Yes

  N/A

Hot Works

• Safety watch (15 minutes & 1 hour sign off after works completed)

  Yes

  No

• Sign to confirm safety watch is complete

  Sign

• Fire fighting equipment

  Yes

  No

• Shields to stop sparks and protect the public and staff

  Yes

  No

  N/A

• Drains covered

  Yes

  No

  N/A

• Are electrical works being carried out?

  Yes

  No

• Equipment to be isolated:

• How has the equipment been isolated:

• Isolation carried out by:

• Isolation carried out at:

• Circuit proved dead at:

• Date/Time circuit proved dead:

  Date

• Subject to the stated conditions the work specified above is authorised to commence

• Name:

• Position:

• Authorised at:

  Date

• Authorisation by PfPLM

  Sign

• I accept the the conditions of the permit as stated above/previous and will ensure that all personnel comply with the conditions of the permit

• Name:

• Position:

• Authorised at:

  Date

• Signature of head contractor

  Sign

• To be completed by the person surrendering the permit and the person receiving the permit

Transferring persons:

• Transferred from (name):

• Date/time transferred from:

  Date

• Transferred to (name):

• Date/time transferred to:

  Date

• The work has been completed to the required quality standards as set out in line with point 7.
  All additional earths have been removed and the isolation removed (electrical only).

• Name:

• Position:

• Date/Time

  Date

• Signature by contractor

  Sign

• The permit is now cancelled

• Name:

• Position:

• Date/Time

  Date

• Signature by PfPLM employee

  Sign

General Manager sign off

• Name:

• Position:

• Date/Time

  Date

• Signature by General Manager

  Sign