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Permit To Work Format

This document outlines the requirements for a height work permit (PTW). It includes sections for permit details like number, dates, location. It describes the work, associated hazards, and required control measures. Control measures include authorization, training, risk assessment, fall protection equipment, scaffolding/platforms, safe access, barricades, and emergency contacts. The permit must be accepted by the receiver and authorized by the issuer after reviewing the risk assessment and control measures.

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Manager Training
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13 views

Permit To Work Format

This document outlines the requirements for a height work permit (PTW). It includes sections for permit details like number, dates, location. It describes the work, associated hazards, and required control measures. Control measures include authorization, training, risk assessment, fall protection equipment, scaffolding/platforms, safe access, barricades, and emergency contacts. The permit must be accepted by the receiver and authorized by the issuer after reviewing the risk assessment and control measures.

Uploaded by

Manager Training
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Contractor Health, Safety & Doc.No.

Environment Management Issue date 15/11/2023


System ( CHSEMS ) Rev # & 00
date

Height Work - PTW


1. PERMIT NO:
Valid From (Date/Time): Valid Upto (Date/Time):

2. Site ID/Site Detail/ Location of Work:

3. DESCRIPTION OF WORK TO BE CARRIED OUT:

4. HAZARDS ASSOCIATED WITH THIS WORK (Please Identify using HIRA)

5. CONTROL MEASURES TO BE IMPLEMENTED

S.N ITEM Yes No Remarks


1 Is the person authorised, competent & trained to work at
height
2 Is the scope of work to be carried out at height is known
and understood.
3 Risk assessment conducted/ Risk evaluated
4 Double lanyard full body Safety harness secured to a fixed
structure / strong anchoring point. All other PPE as
required is being used.
5 Safety net available/ Steel scaffolding / platform rightly erected /
is being used. ( Only for Project Management
Scope i.e. supervision)
6 Safe access to work place / working platform with
handrails and toe guard provided.
7 Is the area cordoned off/barricaded
8 Nearest Emergency Contact Detail available with team.
9 Is energy Isolation required

Issue and acceptance before Work


Acceptance of Work Permission by the person-in –charge (Receiver)
I certify that, I have read and verified this work permit and checklist. I have been informed about the risk assessment
results. I am aware of the risks that can be exposed to. I commit that I will be in line with all safety rules mentioned in
work permit and will not deflect any of them.

Permit Receiver Name : Signature/Date :


Authority to proceed by authorized person ( Issuer )
I reviewed the work permission and check the working conditions. I have reviewed the all aspects of the task/ activity and
am satisfied with the arrangements as detailed in the’ Risk Assessment ‘ have put in place and certify that the activity
detailed above is authorised to proceed.

Permit Issuer Name : Signature/Date :

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