/ ISOLATION PERMIT / Issue Date: 01/07/2016
ReviewDate:01/07/2018

This permit is valid for the time specified on the permit and must be

·  Completed by the person performing the work prior to commencement of any work requiring isolation

·  Used in conjunction with a SWMS or Safe work instruction

·  Checked by the GPNSW Representative prior to work commencing

·  Carried and provided when requested

·  Provided to the GPNSW Representative on completion of work for sign off

Part A Work Details
Name of permit requestor / Business name
Contact Number / Date of work
Location of work- Building room no
Description of work
System to be isolated / ☐Gas
☐Electrical
☐other _ provide detail
Note this excludes a Fire Indicator Panel which has a separate permit.
Permit validation period / From Date: / / Time:____am/pm / To Date: / /Time:____am/pm
GPNSW Authorised Representative / Name / Permit order number from objective
Position

Part B: Assessment and Controls

Assessment / Yes / N/A
·  Safety requirements have been assessed and controls included in safe work method statements
·  The energy source can be adequately and safely isolated
·  Any safety equipment to be used have been maintained and checked prior to use
·  Persons conducting the work are trained and licenced and competent
·  There is adequate fire protection for the work being conducted.
Controls / Yes / N/A
A Work Method Statement has been developed and is specific to and adequate e for the work to be conducted
·  Controls in the Work Method Statement are implemented , including (but not limited to)
·  Lock outs and tags installed to isolated valves or outlets
·  Fire protection equipment installed
·  Area barricaded and signed
·  Working on live electrical installations in accordance with state legislative requirements
·  Ladders or scaffolds are appropriate for the work, inspected and secure
·  Persons who made by affected by energy isolation have been notified(eg employees, customers or contractors)

Part C: Acknowledgement (persons performing the work)

I certify that all necessary precautions as detailed in the permit have been taken to make the area safe for the permitted work
Contractor Name / Company
Signature / Date: / / Time:____am/pm
I have reviewed this permit authorisation and authorise the work to proceed as indicated . I confirm that no conflicting work will be undertaken concurrently with this task
GPNSW Representative Name/Signature / Date: / / Time:____am/pm
Persons Entering/Vacating Isolated work area (attach separate sign in sheet if more room required)
Name / Company / Date / Time in / Time out
Part D:Completion
I certify the job has been done and the area made safe
Contractor Name / Company
Signature / Date: / / Time:____am/pm
Site Manager
I acknowledge that the work has been completed and the permit is returned
Name / Position
Signature / Date: / / Time:____am/pm
Part E. Emergency Authorisation for Lockout release
In the event that the person who put the lock out in place is unable/unavailable to remove the tag and lock, the following procedure is to be followed to authorise the release of the lockout;
The Authorised Officer and the Contractor have checked
☐The work area is clear of personnel tools and equipment
☐It is safe to remove the tag and lock out device and
☐It is safe to re energise the energy source/re-activate the plant
Name / Signature / Date / Time
Contractor
Authorised Representative
Custodian: WHS Manager / Uncontrolled copy when printed / ©GPNSW
Approved by: Place Management / Version: 1.1
Number: SMS-02-FM- A1175702 / Page 1 of 2