TKL PERMIT TO WORK FORM - General Contractors

• Prepared by

• Date & Time

  Date

• Name of person requesting PTW:

• Contractor company name:

• Contractor Emergency contact name:

• Contractor Emergency contact number:

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• Work to commence:

  Date

• To be completed by:

  Date
• Exact location of work:
  Address

• Nature of the work to be undertaken:

• Specific hazards and precautions:

• Physical controls (e.g. safety devices/lock off procedures/checks after work complete etc.):

I declare that I understand the identified risks involved in the work, agree to undertake only the work detailed in the permit to work and will ensure continued implementation of the special precautions and control measures listed.

• Signature of Competent Person:

  Sign

• Date & Time

  Date
Worker declaration:

• “I have read and I understand the permit to work”

• Signature of Worker:

  Sign

• Date & Time

  Date

Mandatory items

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  Select Hi-Visibility Clothing Steel Toe Capped Boots Eye Protection Hand Protection Head Protection Ear Protection

  • Hi-Visibility Clothing
  • Steel Toe Capped Boots
  • Eye Protection
  • Hand Protection
  • Head Protection
  • Ear Protection

Other items (tick if applicable)

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  Select Current employers’ liability insurance Public liability insurance Risk assessments Method statements Safe systems of work Proof of competence qualification or training Other

  • Current employers’ liability insurance
  • Public liability insurance
  • Risk assessments
  • Method statements
  • Safe systems of work
  • Proof of competence qualification or training
  • Other

• Please state other items

• If insurance and health and safety documents have been previously supplied by the contractor’s office, please tick this section

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• Signature of officer issuing the permit

  Sign

• This permit is issued on the understanding that you will abide by all site safety rules:
  • Maintain 5mph when travelling on site
  • Beware of all moving plant/vehicles
  • Be vigilant when working near traffic routes, moving trucks, moving plant
  • Follow all pedestrian walkways whilst on foot
  • Report any un-safe equipment, Practice, or behaviour by any person immediately to the site manager
  • Report any accident, near miss, failure of equipment, major spillage, or release of substance immediately to the site manager
  • Contractors failing to work in a safe manner may be asked to leave site
  

PERMIT ISSUED

• Date issued:

  Date

• Time issued:

  Date

• TKL representative signature:

  Sign

• Contractor signature:

  Sign

PERMIT CLOSED

• TIME PERMIT CLOSED:

  Date

• TKL Representative signature

  Sign