Permit to work checklist
Ks
What does this form include?
This form contains 17 sections:
Permit valid. From Date: Time: To Date: Time:
General
- Site Induction complete
- Green card sighted
- SWMS have been received
Company
Brief description of works
Work Permits - are any of the following work permits required?
- Hot Works
- Energy isolations
- Confined space
- Working at heights
Location
Number of workers
Personal Protective Equipment
- Is there any requirement for PPE
- Does the worker have all required PPE to complete the works
Hot Works Requirements - to be completed by Key Services
- CO2 fire extinguisher provided
- Barricades, warning, signs & spark/flash screens provided
- Work area, trenches, pits clear of flammable liquids, gases or vapours
- Combustibles located within 15m removed or protected with non combustible curtains, metal guards or flame proof covers
- All floor and wall openings within 15m have been covered to prevent the transmission of sparks
- The work area and all adjacent areas have been inspected at the completion of works ensuring no fire conditions were present
- The hot work area and any adjoining areas must be patrolled from the start of the work until 60 minutes after the work is completed
- The work area has been cleaned and clear to prevent any trip or slip hazards
Hot Works Requirements - to be completed by Building Managment / Security
- Fire Sprinklers and / or thermal detectors must be confirmed operational where installed
- Smoke detectors must be isolated in the work area
- The work area and all adjacent areas where sparks may spread were inspected after works complete, ensuring no fire conditions were present
- De-isolation of the smoke detectors within hot works area within 40 mins of the completion of the works
Building Managment / Security
Energy Isolations
- Has approval been given for the isolation
- Testing equipment is in good working order
- Locks and/or tags have been installed
Confined Space
- Has the worker completed confined space training
- Confined space permit completed.
Working at Heights
- Has the worker completed working at heights training
- Has the worker been trained in the use of fall restraint equipment
- Fall restraint system required
- Fall restraint equipment is in good working order and in date
Completion of Work
- Has the work area been restored to normal safety / housekeeping requirements
- Have all Isolations and alarms been reactivated
Signed Key Services
Signed Subcontractor
Use this template