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FORM-03-OHSE-08 General Work Permit (GWP)

1) This document is a general work permit form used to authorize work and ensure safety controls and precautions are in place. 2) It requires information on the project, location, activities, hazards, safety equipment, and authorizing signatures from contractor and owner supervisors and OHSE representatives. 3) The form addresses emergency procedures, time schedules, high risk work requirements, job safety analyses, and confirmation that the work area was returned to a safe condition upon completion.

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Fadil Muhammad
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645 views

FORM-03-OHSE-08 General Work Permit (GWP)

1) This document is a general work permit form used to authorize work and ensure safety controls and precautions are in place. 2) It requires information on the project, location, activities, hazards, safety equipment, and authorizing signatures from contractor and owner supervisors and OHSE representatives. 3) The form addresses emergency procedures, time schedules, high risk work requirements, job safety analyses, and confirmation that the work area was returned to a safe condition upon completion.

Uploaded by

Fadil Muhammad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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Doc.

No : FORM-03-OHSE-08
General Work Permit Revision : 00
Date : 1 Nov 2017
(GWP) Page : 1 of 1

Project Name/ ID: Contractor: Permit No

In case of emergency the permit will be considered invalid.


A. Time Schedule
Start Date: Finish Date:
From (hh:mm): To (hh:mm):
B. Location Activity

C. Safety Controls/ Precautions (assess together between the permit issuer and the permit holder)
C1. High Risk Activities included: [ ] Yes [ ] No If yes: Refer to Special Permit below
Critical High Risk: Others: Permit No. Permit type
[ ] Hot Work [ ] Pressure Testing
[ ] Confined Space Entry [ ] Radiography, [ ] Excavation
[ ] Work at Height [ ] Heavy/ Complex Lifting
[ ] LOTO [ ] ………………………….
C2. Hazards Category Yes No
Apakah identifikasi dan pencegahan bahaya sudah dilakukan?
Apakah APD minimum dan tambahan sudah disiapkan?
Apakah SOP/ WI tersedia dan sudah disampaikan ke pekerja?
Apakah JSA sudah dilakukan dan dikomunikasikan?
Apakah toolbox meeting sudah dilakukan?
Apakah pekerja anda dalam kondisi sehat ?
Apakah petugas keselamatan Ahli K3 tersedia untuk pekerjaan ini?
D. Personal Protective Equipment
[ ] Helmet [ ] Leather Gloves [ ] Ear Plug / Muffs
[ ] Safety Shoes [ ] Safety Glasses [ ] Body Harness
[ ] Rubber Shoes [ ] Safety Goggles [ ] Face Mask
[ ] Cotton Gloves [ ] Face Shield Other
E. Safety Controls (For High Risk Work, the specific permit to work is required to be attached)
Safety Controls as defined in (all documents MUST be attached to the work permit):
General Risk Assessment (Doc. No., revision, date):
Job Safety Analysis (Name, doc. no., revision, date):
Other (Name, doc. no., revision, date):
F. Work Authorisation (All signatures must be completed or else the permit is invalid)

Contractor Supervisor: Owner Supervisor:

Contractor OHSE: Owner OHSE:

Contractor Site Manager: Owner Construction Manager:

G. Nama Pekerja yang Bekerja di Lokasi Kerja Sesuai Ijin Kerja


1 4 7
2 5 8
3 6
9 13 9
H. Confirmation of work completion (Pekerjaan selesai, area dikembalikan ke kondisi awal & aman).
Contractor Supervisor: Owner Supervisor:
Contractor OHSE: Owner OHSE:
Contractor Site Manager: Owner Construction Manager:
Date/ Time :

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