Title Page

  • Date the task is taking place (Permit Valid for 24 hours)

  • Prepared by

  • Location
  • What is the task? (Brief description of the work taking place).

  • What is the name of the contractor?

Inspection

  • Is the contractor performing the task approved and on the suppliers database?

  • Address issue with purchasing department.

  • Name of the site workgroup manager/supervisor?

  • What is the site workgroups manager/supervisors telephone number?

  • All the members of the workgroup site inducted?

  • Perform QSHE 121b Contractor Induction and retain evidence.

  • Are the worker(s) qualified and have all related licences/skills cards been witnessed such as an IPAF 3a/3b licence, in date and evidence taken?

  • What evidence do they have to show they are competent to perform the task?

  • Risk Assessment/Method Statement received and approved

  • Review risk assessment and ensure all precautions stated are in place before work commences.

Significant Hazards and Control Measures . (See Risk Assessment and Method Statement for full details)

  • Type of working at height

  • Hazards

  • Precautions

  • Please describe

  • Fall Prevention/Arrest needed?

Equipment

  • Are you using any of the following

  • What is the date of the last thorough examination (Must be within last 6 months)

  • When was the Scaftag last signed by a competent person (Must be within last 7 days or earlier if involved in incident).

  • What is the construction type and when was the ladder last inspected? (Note Wooden ladders are not allowed. Metal ladders are only allowed for none electrical works)

  • What is the construction type and when was the ladder last inspected? (Note Wooden ladders are not allowed. Metal ladders are only allowed for none electrical works)

  • Are you working outside

  • Are the current conditions and forecast suitable for the type of work.

  • Does the task require electrical/Hot work?

  • Additional permits are required to assess the electrical/ hot work

  • You must complete aditional permits (183a Electrical/183b Hot Work)

  • Are there other work activities in the area

  • Have they been informed and to keep clear and is signage in place as a reminder?

1st Aid Arrangements

  • What are your First Aid Arrangements?

  • Have the First Aid team been made aware of your work on site?

  • First aid team notified

  • Now notifified.

  • Working at height rescue plan required

  • Does this form part of your risk assessment?

  • Review your risk assessment and include details of your rescue plan!

Waste Disposal

  • Are you generating wastes as part of your task?

  • How are you disposing of the waste

  • Name of waste carrier arranged to collect waste

Authorisation and Acceptance

  • On behalf of Schenker Ltd, I authorise the work to be undertaken haveing personally examined the work site and all the documentation to confirm the precautions taken are adequate and conform to DB Schenker's QSHE Policy

  • Issued by:

  • Authorised Signature

  • On behalf of the workgroup , I have personally examined the work location and have read and understood this form. I undertake to ensure that all works are carried out in accordance with this permit and DB Schenker's QSHE Policy.

  • Contractor Supervisor/Manager

  • Authorised Signature

  • End of day. Worksite safe handover declaration.
  • Work day complete?

  • Work progressing as per the job order. All work materials, wastes and equipment have been removed. Any isolations and lock out tags have been removed and services restored. The area is safe to recommence normal working activities

  • Confirmed by the contractor

  • Authorised Signature

  • Witnessed by (Schenker)

  • Date and Time of Sign Off

  • Any final remarks/comments

  • Your remarks

  • Go to Job completion declaration

Job Completion Declaration

  • Task Complete?

  • Work completed to satisfaction, as per the job order. All work materials, wastes and equipment have been removed. Any isolations and lock out tags have been removed and services restored. The area is safe to recommence normal working activities

  • Confirmed by the contractor

  • Authorised Signature

  • Witnessed by (Schenker)

  • Date and Time of Sign Off

  • Any final remarks/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.