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High Risk Permit to Work Form

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Adane Mengsit
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37 views

High Risk Permit to Work Form

Uploaded by

Adane Mengsit
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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INTEGRATED MANAGEMENT SYSTEM

May 2023
Effective Date
PERMIT TO WORK
Page Page 1

High Risk Works Permit to Work


This permit is issued with reference to associated risk assessments and method statements.
Date: ………………………………………….… Location: ...............................................

Site Name/ Work Order Number: ………………………………… Scope of Work: ……………………………………

Requester to fill this section


Requester (name & tel.) Department/ role assigned: Permit Start Date – hrs: ………............
Permit End Date – hrs: ………………..
Certifications for work (attach copies where applicable
Work at Height [ ] Electrical [ ] Defensive Driving [ ] RF [ ]
Fire safety [ ] First aid [ ] Safety passport [ ] NEMA approval [ ]
Permit Local authority approval [ ] Other [ ]
Amenities
Nearest hospital: Nearest police station: Security & Access:
(Name & Tel): (Name & Tel): (Name & Tel):
Permits required (permits must be valid when job is scheduled)
Work at Height/Pole Electrical work [ ] Tower erection/Rigging Excavation/Thrust
climbing/Scaffolding [ ] works [ ] boring/backfilling [ ]
Cutting/welding [ ] Confined space entry [ ] Fiber cable Masonry walling [ ]
pulling/blowing [ ]
Meteorological [ ] Splicing [ ] Fiber connectivity [ ] Digging/Trenching [ ]
Rebar fixing [ ] Concrete pouring [ ] Site clearing [ ] Hazardous Material (Fuelling,
Engine oil etc.) [ ]
Manhole Support/Deployment [ ] Link installation [ ] Generator overhaul [ ]
installation/recovery [ ]
JHA [ ] Design [ ] Work Plan [ ] Quality [ ]
Protective equipment ( share clear photos of workers on site wearing them)
Gloves [ ] Respirators [ ] Safety Harness [ ] Reflectors [ ]
Overall [ ] Helmets [ ] Gumboots [ ] Ear plugs [ ]
Ear muffs [ ] Steel Toe Boots [ ] Others [ ] Face shields [ ]
Safety/Environmental concerns

*PPE should be specific for the task


INTEGRATED MANAGEMENT SYSTEM
May 2023
Effective Date
PERMIT TO WORK
Page Page 2

Hazards Existing Before Work Starts:

Hazards introduced by the works:

Fall Protection

No Description Use
1 Guard rails
2 Edge protection
3 Fall Arrest harness
4 Lanyard
5 Permanent Attachment
6 Safety Nets / Boarding / Bags
7 Ladders Secured (Tied, Footed etc.)
8 Others, please specify

Unauthorized Access

Areas and equipment with unauthorized access


Exclusion Zone
Signages Displayed
Ladders Removed (when not in use)
Watchman (If required)
Extension of Permit:

Note. The Permit to Work can only be extended on the same day of issue. Work that extends into
the following day must have a new Permit to Work.

This Permit to Work is extended between:


Start Time End Time
Name Signature
Designation Phone Number
INTEGRATED MANAGEMENT SYSTEM
May 2023
Effective Date
PERMIT TO WORK
Page Page 3

Clearance of Permit:

The work detailed in this Permit to Work is;

Complete Not complete


All persons under my control have been withdrawn and the work / area / equipment detailed in
this Permit to Work left in a safe condition.

Name Signature

Issue of Permit:

I am satisfied that the conditions of this Permit to Work have been met and the work specified in
this Permit to Work can proceed. The receiver has been briefed on all relevant emergency
procedures:

I declare that workers are in good health condition and free from alcohol/ drug abuse and good working
conditions provided.

Name Signature
Designation Phone Number
Date Time

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