Information

  • Project name and type

  • Client / Site

  • Conducted on

  • Signature

  • Prepared by

  • Location
  • Main Contractor

  • Permit Number: add picture.

  • Work Clearance Form (WCF)

  • Are there WCF’s to cover all work under the Permit?

  • Have all WCF’s been properly filled out?

  • Are there Work Clearance Forms for each day of the work?

  • Are the precautions identified actually in place?

  • Is the Site Manager aware of the work and the precautions to be taken?

  • Have both the contractor and the Site Manager signed the form?

  • For projects that extend beyond one day, is there a new WCF for each day?

  • Comments:

  • Job Hazard Analysis (JHA)

  • Is the JHA readily available on site for review?

  • Has the JHA been discussed with the work crew and have they all signed acknowledgement?

  • Does the JHA contain all the Job Steps, Job Step Hazards and Job Step Controls?

  • Is the JHA being properly followed by the work crew?

  • Have sufficient controls (eliminate, isolate, minimise) been identified for all Job Step Hazards?

  • Are the identified controls in place?

  • Is there a completed Daily Review Sheet for each day of the task?

  • Comments:

  • Permit (PTW)

  • Is the Permit Issuer a Project Manager, Contracts Manager or above?

  • Is the permit readily available on site for review?

  • Does the permit adequately describe the work to be done?

  • Does the permit clearly list any hazards not identified in the JHA?

  • Does the permit adequately describe the requirements to be in place before the work starts?

  • Are the listed requirements actually in place?

  • Has the Permit Holder briefed everyone in the Work Party?

  • Does the permit clearly list the relevant emergency response information?

  • Does the permit clearly state the time and dates for which it is valid?

  • Are renewals up to date using the Work Clearance Form?

  • Has the permit been signed by the Permit Holder and the Permit Issuer?

  • Comments:

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.