Permit to Work Form

Purpose. This form authorises hazardous work on plant and records the isolations, controls and sign-offs required by the Permit to Work and Isolation Policy.

1.When to use this form

A permit must be raised for every task listed in the Permit to Work and Isolation Policy before the task starts. The permit is raised by the permit holder, issued by an authorised issuer at the job, displayed at the job and closed on completion. The permit is recorded in the Permit to Work Register.

2.Describing the work

State the equipment, the location, the work to be done and the people in the work party. Attach the job safety analysis. Where the work changes, the permit must be cancelled and a new permit raised.

3.Isolations

List every isolation point, the type of energy, the lock and tag numbers and who proved the isolation dead. Each member of the work party must fit their personal lock. The area operator must sign that the plant is in a safe state.

4.Controls

Record the controls for the permit type, such as gas testing and standby person for confined space entry, fire watch and hot work screens, or fall protection for heights. Gas test results must be recorded with the time and the instrument number.

• Confined space: gas test, standby person, rescue plan, communication
• Hot work: fire watch, combustibles removed, extinguisher, screens
• Heights: harness, anchor point, rescue plan
• Containment break: line drained, depressurised, protective equipment

5.Issue and close

The issuer and the holder must sign at the job after walking through the isolations and controls. On completion the holder must sign that people and tools are clear and the plant is safe, and the issuer must sign the permit closed before any isolation is removed.

6.Complete the form