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Cold Work Permit Form

The document is a cold work permit template that includes details of the permit, worker details, a description of the cold work activity, a risk assessment checklist, a declaration checklist, and spaces for approver signatures. The template is used to document and approve cold work activities and ensure all necessary safety precautions are in place.

Uploaded by

yasser-roma-888
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
27 views

Cold Work Permit Form

The document is a cold work permit template that includes details of the permit, worker details, a description of the cold work activity, a risk assessment checklist, a declaration checklist, and spaces for approver signatures. The template is used to document and approve cold work activities and ensure all necessary safety precautions are in place.

Uploaded by

yasser-roma-888
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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COLD WORK PERMIT

PERMIT DETAILS

Permit Number Date Issued Start Date and Time End Date and Time

Location/Work Area

WORKER DETAILS

Name Worker ID Gender Skillset

COLD WORK ACTIVITY DESCRIPTION

RISK ASSESSMENT

Has a risk assessment been conducted for the cold work activity? YES No

DECLARATION
I hereby declare that I have:

1. Conducted a thorough inspection of the work area and identified potential hazards. YES No

2. Ensured all necessary precautions have been taken to mitigate risks. YES No

3. Verified that all personnel involved in the cold work activity have received appropriate training and
YES No
possess the required skills.

4. Confirmed that all relevant permits, licenses, and authorizations have been obtained. YES No

5. Verified that the work area is free from any potential hazards or risks associated with cold work YES No
activities.

6. Ensured proper isolation of the work area from unauthorized personnel. YES No
7. Provided workers with appropriate personal protective equipment (PPE).

PPE Checklist:

Safety glasses/goggles

Insulated gloves Thermal

clothing

Anti-slip footwear

Respiratory protection (if required)

Hearing protection (if required) Other

(specify)

8. Established a communication plan for emergencies. YES No

9. Conducted a final inspection before authorizing the cold work activity. YES No

10. Communicated all necessary safety precautions to workers. YES No

11. Ensured that workers are aware of the signs and symptoms of cold stress and are prepared to respond
YES No
accordingly.

12. Confirmed that suitable measures are in place to prevent slips, trips, and falls due to icy or slippery surfaces.
YES No

13. Verified that workers are aware of the proper procedures for handling and storing cold work
YES No
equipment and materials.

14. Implemented a permit-to-work system. YES No

15. Verified that workers have received proper training on cold work safety. YES No

16. Established and communicated an emergency response plan. YES No

DECLARATION
I hereby declare that all necessary precautions and safety measures have been taken, and I understand and accept the responsibility for the safe execution of the cold work
activity described above.

Name, signature and date:

Approver 1 Approver 2 Approver 3

Permit template by:


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