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Permit To Work (PTW) - General

This document is a permit to work that outlines safety procedures and requirements for a job. It requires identification of potential hazards, preparation of the worksite, use of proper protective equipment, supporting documents, and approval from receiving and approving authorities. The permit must be revalidated if work continues for multiple days and handed back once work is completed or incomplete to note the equipment status. It stresses that no work is so urgent that safety cannot be prioritized.

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Nizam Khalid
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1K views1 page

Permit To Work (PTW) - General

This document is a permit to work that outlines safety procedures and requirements for a job. It requires identification of potential hazards, preparation of the worksite, use of proper protective equipment, supporting documents, and approval from receiving and approving authorities. The permit must be revalidated if work continues for multiple days and handed back once work is completed or incomplete to note the equipment status. It stresses that no work is so urgent that safety cannot be prioritized.

Uploaded by

Nizam Khalid
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

PTW No:

PERMIT TO WORK
NO WORK THAT IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY

SECTION 1 - REQUISITION COLD WORK PERMIT ELECTRICAL PERMIT


APPLICANT NAME : ...................................... DEPARTMENT/COMPANY : ......................................... Requisition Expected Completion
LOCATION/FACILITY : ...................................... AREA/UNIT : ......................................... Date : ...................... Date : .........................
EQUIPMENT NO. : ......................................
WORK DESCRIPTION :

SECTION 2 - POTENTIAL HAZARDS


□ Drilling □ Saw / Cold cut □ Hand tools only □ Flame cutting □ Grinding
□ Electrical tools □ Welding □ Vehicle □ Scaffolding □ Power brushing
□ Lifting □ Working at high □ Crane □ Hydro jetting □ Generator / Compressor
□ Pressure test □ Excavating □ Chemical □ Electronic device □ Loading / Unloading
SECTION 3 - WORKSITE PREPARATION / PRECAUTION
□ Tagging □ Secure tools against falling □ Barricade and warning sign
□ Equipment isolation □ Flushed with water □ Others: ..........................................
□ Valve isolated □ Contact maintenance before start work
□ Scaffold erected and safe to be used □ Contact maintenance once completed
SECTION 4 - PERSONAL PROTECTIVE EQUIPMENT
Head, Eye & Face Hearing Hand Foot Body
□ Helmet □ Ear plug □ Cotton glove □ Safety shoes / boot □ Coverall
□ Safety glass □ Ear muff □ Leather glove □ Safety rain boot □ Chemical suit
□ Goggle □ Rubber glove □ Electrical shoes / boot □ Leather / Rubber apron
□ Face / Welding shield □ Chemical glove □ Life vest
SECTION 5 - SUPPORTING CERTIFICATE DOCUMENT
□ Electrical isolation cert. no : ............................ □ Excavation cert. no : ............................................ □ Road construction cert. no : .........................
□ Job Safety Analysis (JSA) □ Drawing no : ........................................................ □ Others : ........................................................
SECTION 6 - JOINT VISIT BEFORE WORK START / APPROVAL
I / We have personally checked the area and the equipment to be worked on and am satisfied the work requested can be carried out safely.
RECEIVING AUTHORITY / REPRESENTATIVE APPROVING AUTHORITY / REPRESENTATIVE

Name : ............................................................... Name : ...............................................................


Designation : ..................................................... Designation : .....................................................
Signature : ......................................................... Signature : .........................................................

AGREED AND SGNED BY RECEIVING AUTHORITY APPROVING AUTHORITY AGREEMENT BY WORK LEADER

Name : ................................................................. Name : ................................................................. Name : .................................................................


Signature : ........................................................... Signature : ........................................................... Signature : ...........................................................
Date : ............................... Time : ........................ Date : ............................... Time : ........................ Date : ............................... Time : ........................

SECTION 7 - REVALIDATION
DATE RECEIVING AUTHORITY APPROVING AUTHORITY AA REPRESENTATIVE WORK LEADER

SECTION 8 - HANDBACK
□ Incomplete hand back (equipment status, reason for hand back, etc) □ Work completed □ Housekeeping completed
RECEIVING AUTHORITY ACCEPTED BY APPROVING AUTHORITY

Name : ...................................................... Date : ................................ Name : ...................................................... Date : ................................


Signature : ................................................ Time : ................................ Signature : ................................................ Time : ................................

STOP WORK AND EVACUATE AREA ON HEARING OF EMERGENCY ALARM


Distribution - Original : Display at worksite Copy No. 1 : Guard House (HSE) Copy No. 2 : Receiving Authority

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