PERMIT TO WORK - AUTHORISATION DETAILS

  • Details of the contractor undertaking the activities:

  • Operative in charge of the listed activities:

  • Description of works/activities being undertaken:

  • General risk controls implemented to minimise risk within the work area (select all that apply)

  • Additional general risk controls being used within the work area:

  • This permit is valid from:

  • This permit is valid until:

  • This permit covers the following work activities. The following section contains details of control measures that are being implemented to ensure safe working at all times.

  • Signed on behalf of the premises owners/work organiser

  • Signed on behalf of the contractor responsible for completing the listed activities

PERMIT TO WORK - HAZARD INDENTIFICATION AND RISK CONTROL DETAILS

  • This form can be used to provide permission to persons who are carrying out works where a permit to work is required. While basic questions and information is provided against each activity, it is the responsibility of the work place controller and the operative carrying out the works to ensure safe systems of work are in place at all times. This permit to work may be supported by other documentation such as schematic drawings, Risk & Method Statements (RAMs), MSDS sheets, Asbestos Registers etc.

  • HOT WORKS - does the activity involve hot works such as welding, cutting, soldering etc?

  • You have identified that HOT WORKS are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • WORK AT HEIGHT - does the activity involve work at height where controls are required to ensure safe working? Work at height is defined as any work that is undertaken where a fall can occur. This could include falls into excavations not just falls from above ground level?

  • You have identified that WORKS AT HEIGHT are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • WORK ON PLANT - does the activity involve working on industrial plant such as boilers, conveyors, or other large machinery where controls are required to ensure safe working?

  • You have identified that WORKS ON PLANT are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • CONFINED SPACES - does the activity involve any work within confined spaces such as within drains, access chambers, etc where controls are required to ensure safe working?

  • You have identified that CONFINED SPACE ACTIVITIES are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • ELECTRICAL WORKS - does the activity involve any electrical works where controls are required to ensure safe working?

  • You have identified that ELECTRICAL WORKS are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • USE OF FLAMMABLE MATERIALS - does the activity involve flammable materials such as gases, oils, solvents etc where controls are required to ensure safe working?

  • You have identified that FLAMMABLE MATERIALS are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • USE OF HAZARDOUS CHEMICALS - does the activity involve the use of hazardous chemicals where controls are required to ensure safe working?

  • You have identified that HAZARDOUS CHEMICALS are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • ASBESTOS - does the work activity involve working with identified or suspected Asbestos Containing Materials (ACMs) where controls are required to ensure safe working?

  • You have identified that ASBESTOS CONTAINING MATERIALS are involved in this activity. please select the controls that you have in place or are putting in place to minimise any risk.

  • If other controls are being implemented which are not listed above, please list them in this section

  • OTHER HIGH RISK ACTIVITY - Is there any other high risk activity which needs a permit to allow works to take place which is not listed above?

  • Use this area to list the activity and any relevant control measures that are being implemented to minimise any risk.

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