PERMIT TO WORK
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General Work
Hot Work
Chemical Work
Cold Work
Work at Height
Electrical Work
Special Work
Excavation Work
Permit Details
Worker Details
Risk Assesment
Declaration
Permit Details
Permit Number
Date Issued
Start Date & Time
End Date & Time
Site
Site 01
Site 05
Site 06
Site 07
Zone
Zone 01
Zone 05
Zone 06
Zone 07
Area
Area 01
Area 02
Area 03
Area 04
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Worker Details
Total Workers
1
2
3
1st Worker Details
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Skill Set
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2nd Worker Details
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Skill Set
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Risk Assesment
Has a risk assessment been conducted for the work activity?
1. Conducted a thorough inspection of the work area and identified potential hazards.
2. Ensured all necessary precautions have been taken to mitigate risks associated with the work activity.
3. Verified that all personnel involved in the work activity have received appropriate training and possess the required skills.
4. Confirmed that all relevant permits, licenses, and authorizations have been obtained.
5. Verified that the work area is free from any potential hazards or risks associated with the work activity.
6. Provided workers with appropriate personal protective equipment (PPE) for the work activity.
Safety goggles
Gloves
Safety footwear
Hard hat
Hi-vis vest
7. Established a communication plan for emergencies.
8. Conducted a final inspection before authorizing the work activity.
9. Communicated all necessary safety precautions to workers.
10. Verified that workers are aware of the proper procedures for handling tools and equipment related to the work activity.
11. Ensured that workers are trained in the safe operation of machinery and equipment relevant to the work activity.
12. Implemented a permit-to-work system, if required.
13. Verified that workers have received proper training on general safety measures and practices.
14. Established and communicated an emergency response plan.
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Declaration
I hereby declare that all necessary precautions and safety measures have been taken, and I understand and accept the responsibility for the safe execution of the work activity described above.
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Witness
Select Worker Witness
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Attachment
UPLOAD
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Assign to
Select Worker Involved
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