Permit To Work

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Authorisation Form

- Step 1 of 4

This permit is only valid for the day of issue, on every occasion that additional work is carried out a new permit is to be issued.

Contractor Company:

Contractor Contact:

Location Of The Work:

Work Start Date / Time:

Date

Time

Work Completion Date / Time:

Date

Time

Scope of work to be completed:

Representative responsible for supervising contractor:

Tasks to be performed include, or could include:

Tasks To Be Completed

Hot work (including welding, cutting and grinding etc)
Work in high traffic areas
Work on Fire Alarm System
Evacuation or Trenching
Work likely to disturb asbestos
Work likely to produce dust or fumes
Use of Mobile Plant (eg. forklift, crane)
Work likely to produce dust or fumes
Confined space entry
Use of Pneumatic tooling
Use of Hazardous chemicals (Paints, Fuels, Solvents, etc)
Other - Please state below

Other Task (Specify):

Contractors Declaration:

Have you provided a Specific Safe Work Method Statement (or other safe work procedure eg: Job Safety Analysis) for the work to be performed, which details controls measures for the hazards listed above?

Yes
No

The above location has been thoroughly inspected and safety precautions carried out?

Yes
No

Where applicable, automatic fire alarms and detection systems/zones have been isolated?

Yes
No

Have you ensured adequate segregation of works from staff, visitors or members of the public?

Yes
No

Are you competent to safely complete these works?

Yes
No

Additional Restrictions / Control Measures:

Authorisations

Signature of Contractor Responsible for the work:

Print Name *

First

Last

Contractor Responsible - Email *

Signature of Person Authorising the work:

Name *

First

Last

Email - Authorising Person *

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