Trailer Checks Permit To Work

• Permit No.000001

• Contracting Company

• Responsible Person

• Mobile Phone Number:

• Additional Personal

• Location
  Address

• Conducted on

  Date

• Prepared by

• Activity Risk Level

  Low

  Medium

  High

• Additional Comments

General details

• Job Details

• Permit Start Time

  Date

• Estimated Permit End Time

  Date

• Is there a risk assessment and method statement/SSOW available for the works

  Yes

  No

• State Reason

• is this reason acceptable?

  Yes

  No

• Reject Permit Application

• Are the works being undertaken by competent personal

  Yes

  No

• Are these documents available

  Yes

  No

• State Reason

• is this reason acceptable?

  Yes

  No

• Reject permit application.

• Are the appropriate insurance documents available?

  Yes

  No

• State reason

• is this reason acceptable?

  Yes

  No

• Reject permit application

• PPE Requirements:

• Please state what PPE is required

  Select Safety boots Hard hats Safety Gloves Hi- Vis Clothing Hearing Protection Harness Respirator Eye Protection

  • Safety boots
  • Hard hats
  • Safety Gloves
  • Hi- Vis Clothing
  • Hearing Protection
  • Harness
  • Respirator
  • Eye Protection

• Will this work encroach upon any other work, for which a permit to work will be/has been issued?

  Yes

  No

• Have precautions and a consultation taken place

  Yes

  No

• State reason

• Do All Attendees Have A Valid DFDS Immingham Induction?

  Yes

  No

• Reject Permit application.

• Additional Comments

Hazards and Precautions to be taken

• Is the area clear and free from hazards?

  Yes

  No

• What actions have taken place?

• Will their be sufficient protection against others entering the works area?

  Yes

  No

• Is the Trailer isolated and free from all sources of energy?

  Yes

  No

• Is the Trailer safe to be worked on?

  Yes

• Tools,Plant,Equipment in good working order, free from damage and have in date test/service certificates were relevant?

  Yes

  No

• Are the weather conditions acceptable?

  Yes

  No

• Additional Comments

Contractor Acceptance & Permit Authorisation

• I confirm that I have accepted responsibility for the works to be carried out, and will ensure all health and safety and hygiene instructions are complied with. Competent authorised persons will carry out the works in accordance with the risk assessment & method statement

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• I am competent to authorise this permit, subject to the conditions indicated the works may proceed

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date

Contractor Completion & Permit Closure

• I certify that

• undefined

  Select The work has been completed Equipment has been removed Plant and machinery has safely been returned to service Disable fire protection zones have been reinstated

  • The work has been completed
  • Equipment has been removed
  • Plant and machinery has safely been returned to service
  • Disable fire protection zones have been reinstated

• Full Name and Signature of Person in Charge

  Sign

• Date and Time

  Date

• Full Name and Signature of Authorizing Person

  Sign

• Date and Time

  Date