Title Page

  • Site conducted

  • Document No.

  • Site

  • Brief description of work activity

  • Location of Work

  • ACCESS ONLY

  • Conducted on

  • Competent Person:

  • Personnel

1. Work Activity

  • Location: Where is the task being completed?

  • Brief description of the works:

  • Access Only

Documentation

  • Risk/Activity Assessment Ref:

  • Risk Assessment photographic record

  • Date on Risk Assessment

  • Is the Risk Assessment suitable and sufficient?

  • Risk Assessment prepared by:

  • Method Statement Ref:

Higher Risk Work Activity Assessment

  • Entry in to a Confined Space? (includes work in or access to any void area, including roof voids

  • Permit to Work issued

  • LV Electrical? (any works requiring multiple points of isolation)

  • Permit to Work issued

  • HV Electrical? (any works on any part of the HV system)

  • Permit to Work issued

  • Fire & Life Safety Systems? (fire alarm/HSSD/Extinguishers - work requiring isolation of a complete system or multiple zones)

  • Permit to Work issued

  • Hot Works? (any works with a naked flame, or where there is a risk of causing fire or fumes)

  • Permit to Work issued

  • Mechanical Isolation? (multiple isolation of any Gas, Pressure or Water system for intrusive works - excluding visual inspections)

  • Permit to Work issued

  • Working at Height? (for work on any specialised access equipment, roofs, or any unprotected high places)

  • Permit to Work issued

  • Other Task Specific Permit?

  • Specify

  • Permit to Work issued

  • Assessed by: (the Competent Person completing the activity)

  • Company:

  • Contact telephone No:

Permission to Proceed

  • Start Time:

  • End Time:

  • Site Induction Completed

  • Authorised by: (the Responsible Person)

  • Contact Tel. No:

Completion or Cancellation of Work

  • Competent Person:

  • Date & Time of completion/cancellation

  • Responsible Person:

  • Date & Time of completion/cancellation

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.