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Type / Prefix & no.
Type / Prefix & no.
Type / Prefix & no.
SECTION 1 ISSUE PLEASE PRINT DETAILS
Permit Receiver/Competent Person in charge of work / Location of work/equipment to be worked on
Name of persons detailed to carry out work / Details of work to be done
Risk Assessment attached? /
Yes / No / Reference / Safety method Statement or Safe System of Work attached? / Yes / No / NA / Reference
SECTION 2 ISOLATION of electrical or mechanical plant, liquid or gas pipeline or other energy source - give details
Item / Lock location & reference / Isolated by: Print name
Attached Isolation Sheet / Yes / No / Reference / Location of Keys
SECTION 3 PREPARATIONS/PRECAUTIONS tick box
Yes / No / NA / Yes / No / NA
1. Has every source of energy been isolated? / 5. Are vessels/pipes free of toxic/flammable, gas, dangerous sludge & depressurized?
2.Have all isolations been tagged? / 6. Any asbestos containing materials present
present?
3. Have all isolations been tested? / 7. Are the risk assessment control measures in place measuresimimplimented implemented?
4a. Does the standard of pipeline isolation meet minimum Corporate standards? / 8. Other precautions/control measures required (specify)
4b. If not, specify additional precautions
SECTION 4PERSONAL PROTECTIVE EQUIPMENT tick box
Site Standard / Other specify
Safety Goggles
Hearing protection
Respiratory protection / Specify type
SECTION 5 TIME LIMITS
From hrs / On / / / To hrs / On / /
Max 24 hours See overleaf for details of time extensions allowed
SECTION 6AUTHORIZATION Permit Issuer/Authorized Person / SECTION 7RECEIPT Permit Receiver/Competent Person in charge
I certify that it is safe to work in the area/on the equipment detailed in Section 1 above and that all safety measures detailed in Section 2-4 have been carried out/complied with. ALL OTHER PARTS ARE DANGEROUS / I have read, understood and accept the requirements of this permit. I will ensure that everyone working under my supervision will strictly follow the requirements of this permit. I have checked the isolations.
Print Name / Date / Time / Print name / Date / Time
Signed / Signed
SECTION 8 SUSPENSION OF GENERAL WORK PERMITthis is an exception and must be signed on the frontof ‘on the job’ copy
I certify that the task for which this Permit was issued has now been suspended. We have agreed and implemented a procedure which complies with the criteria noted in the checklist in Section 13 overleaf
Signed
Permit receiver/Competent person in charge / Signed
Authorized person
Date / Time / Date / Time
SECTION 9CLEARANCEPermit Receiver/Competent person in charge / SECTION 10CANCELLATION Permit Issuer/Authorized Person
I certify that the work for which the permit was issued is now COMPLETED and that all persons at risk have been WITHDRAWN and WARNED that it is NO LONGER SAFE to work on the plant specified on this permit and that GEAR TOOLS and EQUIPMENT are all CLEAR / This permit to work is hereby CANCELLED, all plant is restored to safe operating conditions, including the replacement of guards.
Print name / Date / Time / Print name / Date / Time
Signed / Signed
S2 General Work Permit Jan12