1. WORK DETAILS
Work Area:
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Area Supervisor:
XXXXXXXXXX
Vendor:
XXXXXXXXXX
Where is the work being done?
Low Risk Area
Medium Risk Area
High Risk Area***
Permit Validity
Date
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Start Time
XXXXXXXXXX
Completion Time
XXXXXXXXXX
**The Area Supervisor, Manager or Process Owner is informed of the work to be carried out.
Yes
No
***The Site Lead must be informed when work is carried out in a high risk area
2. OTHER ASSOCIATED PROCEDURES/ PERMITS/ METHOD STATEMENTS (To be Completed by Permit Issuer)
REFERENCE SOP/PERMITS REMARKS
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX
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3. HAZARD IDENTIFICATION & CONTROL MEASURES (To be Completed by Permit Issuer)
1. Corrosive Chemical
9. High/ Law Pressure
17. Compressed
25. Hand Tools
2. Flammable Materials
10. High/ Law Temperature
18. Use of Ladder
26. Power Tools
3. Explosive Materials.
11. Electricity & Power Tools
19. Scaffolding
27. Underground
4. Explosive Gas/ Dust
12. Accidents that can happen from
20. Unsafe Access
28. Residual Pressure
5. Heated Liquid
13. Active Machines
21. Brittle Surface
29.
6. Steam
14. Self Active Machines
22. Slippery Floor
30.
7. Underground Pipelines
15. Traffic & Vehicle Movement
23. Entangled Materials
31.
8. Fumes/ Dust
16. Confined Space
24. Hot Surface
32.
4. SPECIAL HAZARDS AND MEASURES TO CONTROL THEM (For this the issuer should consult the authorized officer)
Have awareness of working with live electrical connections/ high voltage connections done?
Tested after power shut off
Yes
No
Name : _________________
Signature : _________________
5. CONTROLS TO BE IMPLEMENTED TO REDUCE HAZARDS IDENTIFIED (To be Completed by Permit Issuer)
Hazard No Specific Controls Hazard No Specific Controls
* Please attach a separate sheet if more space is required
6. EQUIPMENT INSPECTION (To be Completed by Permit Issuer)
PPE Used PPE Used Equipment Used Equipment Used
1. Safety Helmet
7 Gas Masks
1. Rescue Equipment
5.2 …......................
2. Safety Shoes
8 Face Shield
2. Power Tools
5.3 ….......................
3. Safety Goggles
9 Other
2. Power Tools
5.3 ….......................
4. Hand Gloves
9.1 …......................
4. Lifelines
5.5 …......................
5 Safety Harness
9.2 …......................
5 Other
5.6 …......................
6 Ear Protection
9.3 …......................
5.1 …......................
5.7 …......................
7. METHOD STATEMENT (To be completed by Permit Issuer)
1. Asbestos
8.1 …......................
2. Working with high voltage electrical systems and equipment
8.2 …......................
3. Working with low voltage electrical systems and equipment
8.3 …......................
4. Deep excavation
8.4 …......................
5. Load testing in lifting operations
8.5 …......................
6. Pressure testing
8.6 …......................
7. Demolition
8.7 …......................
8. Other
8.8 …......................
9. ACCEPTANCE – Persons Performing the Task understand the requirements in Sections 1 to 5
I/we understand the nature of the work to be done and are aware of the hazards identified in Section 2 / Section 3 of this permit. I am/we also aware of the controls which have been identified and implemented
Prior to Starting Work
On Completion of Work
Print Name
Signature
Signature
Works Supervisor (Permit Holder)
