V-HSF040 Entry/Access (Limitation of Access) Permit

• Site Conducted

  Select

• Conducted On

  Date

• Reference No.

• Address

• Contractor

• Competent Person Supervising Work

  Sign

• Other Members of Team

  Sign

• Other Members of Team

  Sign

• Other Members of Team

  Sign

• Other Members of Team

  Sign
• Location (Location entrance(s) must be signed with the notice of access control
  Address

• Risk Assessment and Method Statement

  Yes

  No

• Approved Risk Assessment and Method Statement No.

• Checklists (Permit will not be approved if checklists are not attached.

  Yes

  No

• Any special precautions required?

The persons designated above (and only those persons) are hereby granted permission to enter and work in the controlled location in accordance with the approved risk assessment and method statement.

• Permit to Commence

  Date

• Permit to Expire

  Date

• This permit cannot cover more than one shift and can only be issued for the maximum of a 12-hour period.

  Sign

• I hereby confirm that all persons working within the scope of this permit will be adequately briefed on its content and will abide by the conditions of the permit.

  Sign

• The work for which this permit was issued is complete and all persons, materials and equipment under my supervision have been withdrawn.

  Sign

• I certify that I personally examined the work area detailed above and that the work specified has been satisfactorily completed.

  Sign

• Any Comments

This permit is now cancelled - a new permit will be required if work is to continue.

This checklist must be completed by the trade contractor's competent, nominated person and reviewed by the appointed person before a permit can be issued. A copy of the checklist must also be attached to the permit.

• Is there adequate access and agress?

  Yes

  No

• Has a Risk Assessment and Method Statement been approved?

  Yes

  No

• Is monitoring equipment required (and if so has it been calibrated?)

  Yes

  No

  N/A

• Have all harmful substances been removed from the space?

  Yes

  No

  N/A

• Are all those entering the area trained and competent?

  Yes

  No

• Is a rescue plan in place and approved?

  Yes

  No

  N/A

• Are rescue equipment and personnel readily available for the duration of the work?

  Yes

  No

  N/A

• Has the rescue team been trained in its use?

  Yes

  No

  N/A

• Has a system of communication been established and are emergency contact numbers available?

  Yes

  No

• Have all services to the area been isolated or disconnected?

  Yes

  No

• Is the correct personal protective equipment (PPE) readily available and fit for use?

  Yes

  No

  N/A

• Are all the necessary signs and barriers available?

  Yes

  No

• Is intrinsically safe task lighting available?

  Yes

  No

• Is there a risk of spark or fire? (If Yes, a hot-work permit is required)

  Yes

  No

  N/A

• Has a gas-free certificate been issued?

  Yes

  No

• If working in riser shafts, lift shafts, roof areas - is adequate fall prevention in place?

  Yes

  No

  N/A

• If working in riser shafts, lift shafts, roof areas - have precautions been taken to avoid falling materials and tools?

  Yes

  No

  N/A

• If working in riser shafts, lift shafts, roof areas - has the area been checked for potential fragile surfaces?

  Yes

  No

  N/A

• Any Comments?