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Permit to Work Checklist Form
Please fill the form below
1
Step 1
2
Step 2
3
Step 3
Permit Request
Work Activity Title:
This field is required.Please enter value
Specified high-risk work tasks covered to work by this permit:
Hot Work
Confined Space
Excavation
Plant Isolation
Work at Heights
Live Electrical Maintenance Work
Others
This field is required.Please enter value
Please specify:
This field is required.Please enter value
Start of Work:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
End of Work:
This field is required.Please enter value
Date format is invalid, please check it again
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Permit Request (On-site supervisor of the contractor/workers who have been engaged to perform the work)
I have developed and/or reviewed the Risk Assessment and required Control Form/s relevant to this work activity:
Yes
No
N/A
This field is required.Please enter value
Next
I have consulted with relevant people to ensure that controls are adequate:
Yes
No
N/A
This field is required.Please enter value
I am competent to coordinate this work activity in accordance with the attached Risk Assessment and Control Form/s:
Yes
No
N/A
This field is required.Please enter value
I shall undertake to implement all planned and necessary controls to ensure the health and safety of those completing or impacted by the activity:
Yes
No
N/A
This field is required.Please enter value
I shall monitor hazards and control methods throughout the work activity:
Yes
No
N/A
This field is required.Please enter value
I am requesting this Permit to be reviewed, registered and numbered by the Permit to Work Authorised Person:
Yes
No
N/A
This field is required.Please enter value
Person Engaging Contractor/Worker Review
I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s and provided feedback to the contractor/workers:
Yes
No
N/A
This field is required.Please enter value
Next
Previous
I confirm as the person who engaged the contractor/worker, I will monitor the methods of work and the implementation of the proposed controls to ensure that standards for health and safety are being achieved throughout the works:
Yes
No
N/A
This field is required.Please enter value
I have informed the relevant person/s for the area that the work is being performed in, the full scope of works to be completed by the contractor/workers and the processes developed for supervising and enforcing the works:
Yes
No
N/A
This field is required.Please enter value
Authorization
I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s:
Yes
No
N/A
This field is required.Please enter value
I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s:
Yes
No
N/A
This field is required.Please enter value
Previous
Submit
