Information
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Project name and type
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Client / Site
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Conducted on
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Signature
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Prepared by
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Location
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Main Contractor
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Permit Number: add picture.
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Work Clearance Form (WCF)
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Are there WCF’s to cover all work under the Permit?
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Have all WCF’s been properly filled out?
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Are there Work Clearance Forms for each day of the work?
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Are the precautions identified actually in place?
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Is the Site Manager aware of the work and the precautions to be taken?
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Have both the contractor and the Site Manager signed the form?
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For projects that extend beyond one day, is there a new WCF for each day?
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Comments:
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Job Hazard Analysis (JHA)
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Is the JHA readily available on site for review?
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Has the JHA been discussed with the work crew and have they all signed acknowledgement?
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Does the JHA contain all the Job Steps, Job Step Hazards and Job Step Controls?
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Is the JHA being properly followed by the work crew?
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Have sufficient controls (eliminate, isolate, minimise) been identified for all Job Step Hazards?
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Are the identified controls in place?
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Is there a completed Daily Review Sheet for each day of the task?
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Comments:
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Permit (PTW)
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Is the Permit Issuer a Project Manager, Contracts Manager or above?
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Is the permit readily available on site for review?
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Does the permit adequately describe the work to be done?
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Does the permit clearly list any hazards not identified in the JHA?
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Does the permit adequately describe the requirements to be in place before the work starts?
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Are the listed requirements actually in place?
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Has the Permit Holder briefed everyone in the Work Party?
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Does the permit clearly list the relevant emergency response information?
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Does the permit clearly state the time and dates for which it is valid?
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Are renewals up to date using the Work Clearance Form?
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Has the permit been signed by the Permit Holder and the Permit Issuer?
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Comments: