PERMIT TO WORK

Project Name: *

Reference No.:

Location/Work Site: *

Permit To Work Services *

Type of Services: *

Title/Position: *

Prepared by: *

Contractor/Sub-contractor name doing the work *

Hard Hat (Hard Hats and Helmets) *

Yes

Eye and Face Protector (Safety Glasses, Goggles, Faceshields, and welding helmets) *

Yes

Body Protector (Reflective Vest, Whole Body Suits, Pants) *

Yes

Hand Protector (Gloves) *

Yes

Foot Protector (Safety Shoes) *

Yes

Harness (Lanyard) - If Needed

Yes

Ear Protector (Ear Plugs)- If Needed

Yes

Respiratory Protector (Mask)- If Needed

Yes

STOP!!! CALL OUR TEAM NOW!!!
(If you answer "NO" in any of the PPE questions above)

We're you asked to continue? *

Yes

Site Activities

Activity Start Date

Activity Start Time

Activity End Date

Activity End Time

Specified High Risk Work Tasks

Tools

Other Tools

Equipments

Other equipments

Upload Selfie if you agree on the above showing that you are wearing the proper PPE: *

Selfie Location: *

Worker Full Name:

Worker Email: *

Worker Contact Number: *

Worker Signature: *

Clear

Is there a Supervisor around? *

I am requesting the Permit to be reviewed, registered and numbered by the Permit to Work Authorised Person. *

YES

N/A

I confirm as the person who engaged the contractor/worker. I will monitor the methods of work and the implementation of the proposed controls to ensure that standards for health and safety are being achieved throughout the works. *

YES

N/A

Supervisor Full Name: *

Supervisor Email: *

Supervisor Contact Number: *

Supervisor Signature: *

Clear

Do you have a Project Manager around? *

I have reviewed the content of all documents including the Risk Assessment and required Control Form/s. *

YES

N/A

I have registered this permit in the Permit To Work Register, allocated it a number and have written the number on all associated documents. *

YES

N/A

Full Name of Permit to Work Authorised Person/ Project Manager *

Authorised Person/Project manager Contact Number: *

Authorised Person/Project manager Email: *

Authorised Persons/Project manager Signature: *

Clear

Position *