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Cold Work Permit Checklist Form
Please fill the form carefully
1
Step 1
2
Step 2
3
Step 3
Audit
Scope of works:
This field is required.Please enter value
Permit valid from:
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 valid to:
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
Potential Hazards and Controls
Depressurizing:
Yes
No
N/A
This field is required.Please enter value
Draining:
Yes
No
N/A
This field is required.Please enter value
Adequate lighting:
Yes
No
N/A
This field is required.Please enter value
Safety tags and locks:
Yes
No
N/A
This field is required.Please enter value
Electrical isolation:
Yes
No
N/A
This field is required.Please enter value
Next
Mechanical isolation:
Yes
No
N/A
This field is required.Please enter value
Exposure to moving/rotating machinery:
Yes
No
N/A
This field is required.Please enter value
Confined space:
Yes
No
N/A
This field is required.Please enter value
Fall protection:
Yes
No
N/A
This field is required.Please enter value
Standby man:
Yes
No
N/A
This field is required.Please enter value
Ventilate properly:
Yes
No
N/A
This field is required.Please enter value
Warning notice:
Yes
No
N/A
This field is required.Please enter value
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Potential flammable/explosive atmosphere:
Yes
No
N/A
This field is required.Please enter value
Potential high temperature:
Yes
No
N/A
This field is required.Please enter value
Potential exposure to hazardous materials:
Yes
No
N/A
This field is required.Please enter value
Excavation works:
Yes
No
N/A
This field is required.Please enter value
Personnel Protective Equipment
Select PPE to be used:
Working Cloves
Face Shields
Goggles
Ear Plugs
Gas Masks
Others
This field is required.Please enter value
Please specify:
This field is required.Please enter value
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