PTW Inspection Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Description of the Activity

• Work Permit Number:

• Location: (Building, Level, Area, nearest location Reference)

Work Permit Activity and Document Approval

• Are approved Risk Assessment & Method Statement (RAMS) / Safe System of Work (SSOW) available at the worksite?

  Yes

  No

  N/A

• Is the work activity supervised by a responsible person (Receiver's complete information)?

  Yes

  No

  N/A

• Has the Work Permit been signed by the Issuer?

  Yes

  No

  N/A

• Has the Work Permit been signed by the Receiver?

  Yes

  No

  N/A

• Has a joint inspection been conducted prior to the activity?

  Yes

  No

  N/A

• Is the work being carried out as scheduled?

  Yes

  No

  N/A

• Do the workers have the right tools/ equipment as stated on the RAMS/ SSOW?

  Yes

  No

  N/A

• In a confined space, is there air/ gas test and emergency exit recommendations available?

  Yes

  No

  N/A

Lock Out/ Tag Out (LOTO) Activity and Documentation Approval

• Is the equipment under maintenance isolated from any source of energy drained from of any liquids?

  Yes

  No

  N/A

• Are the LOTO tags fitted at the correct location?

  Yes

  No

  N/A

• Are all the information on the tags completed properly?

  Yes

  No

  N/A

• In the case the equipment under maintenance could contain residual energy, has it been adequately discharged from the equipment?

  Yes

  No

  N/A

• Has the person performing the task been grained on HSE-6-200 LOTO Procedure?

  Yes

  No

  N/A

• Where no device can be fitted to isolate the energy source, have alternative control measured been applied?

  Yes

  No

  N/A

• After isolation, is it ensured that no associatedcontrol devices have the capability of energizing the equipment?

  Yes

  No

  N/A

• Do the RAMS include LOTO details?

  Yes

  No

  N/A

• For any isolation of Safety/ Fire System, is there an approved Safety/ Fire System Isolation checklist at the work site (must be approved by the Fire Chief)?

  Yes

  No

  N/A

• Have 911 and FDAS been notified of the isolation of Safety/ Fire System?

  Yes

  No

  N/A

• Safety Officer:

  Sign

• Receiver:

  Sign