GENERAL WORK PERMIT

1. WORK DETAILS
(To be Completed by Permit Issuer)
Work Area: XXXXXXXXXX Area Supervisor: XXXXXXXXXX Vendor: XXXXXXXXXX
Where is the work being done? Low Risk Area Medium Risk Area High Risk Area***
Permit Validity Date XXXXXXXXXX Start Time XXXXXXXXXX Completion Time XXXXXXXXXX
**The Area Supervisor, Manager or Process Owner is informed of the work to be carried out.
***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)
XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX
XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX
XXXXXXXXXX XXXXXXXXXX XXXXXXXXXX
3. HAZARD IDENTIFICATION & CONTROL MEASURES (To be Completed by Permit Issuer)
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


Name : _________________

Signature : _________________
5. CONTROLS TO BE IMPLEMENTED TO REDUCE HAZARDS IDENTIFIED (To be Completed by Permit Issuer)
* Please attach a separate sheet if more space is required
6. EQUIPMENT INSPECTION (To be Completed by Permit Issuer)
7. METHOD STATEMENT (To be completed by Permit Issuer)
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)

Special Hazards And Measures To Control Them (For This The Issuer Should Consult The Authorized Officer)

Is it a maintenance related to electricity ? Tested after power shut off


Have awareness of working with live electrical connections/ high voltage connections done? Tested after power shut off


Name : _________________

Signature : _________________

8. AUTHORISATION – I certify that the persons working under this permit have been instructed in the requirements in Sections 1 to 7 (Permit Authoriser)

8.1 Authorisation
Signed : Process Owner
Name :
Date :
Time :
Signed : Permit Issuer
Name :
Date :
Time :
Signed : Permit Issuer
Name :
Date :
Time :

Name : _________________

Signature : _________________

PERMIT ISSUING

(Permit Issuer)

My signature below indicates that I have completed the risk assessment, actions, necessary communications and trainings to permit receiving party and location/ area/ machine is safe to start the work.

Name : _________________ 
 
Date & Time : _________________ 
 
Signature : _________________

(Permit Receiver)

My signature indicates that I fully understand and will fully comply with all conditions and requirements of this Permit to Work. 

Name : _________________ 
 
Date & Time : _________________ 
 
Signature : _______________

SUPERVISION (Tick the Appropriate Box)

If it is intermittent supervision, Frequency of Supervision
Time Signature Time Signature Time Signature Time Signature
1st Check 4th Check 7th Check 10th Check
2nd Check 5th Check 8th Check 11th Check
3ed Check 6th Check 9th Check 12th Check


Name : _________________

Signature : _________________