Work permit

Working document 1
Page 1/2

Apply form
Location

Work description
Procedure

Tools
Vehicles
Number of persons
Start date
Work time from
Special permits

(To be filled in by applier)

Department
................................................
................................................
Equipment n
...............................................
................................................
...................................................................................................
..................................................................................................
..................................................................................................
mounting/demounting
chopping / boring
opening of installations
grinding
entering closed space
high pressure spraying
burning/gouging/welding sand blasting
X-rays/radiation work
digging
hoisting / lifting
placement of scaffold
.
..................................................................................................
..................................................................................................
............................... Marks
..............................
...............................
...............................
............................... Persons < 18 years Yes
...............................
No
.............................. End date
..............................
.............................. Work time - till
..............................
Dig permission
Scaffold permission
Entering closed space
Hot work permission
Works on piping
.

MEASURES BEFORE STARTING THE WORKS

(To be complete by the distributing department)
General measures
Check environment combustible material
Free connect apparatus electrical
Block apparatus mechanical
Condition closed space with/without gas free certificate
Foresee signalisation
Mark out work space (white/red or yellow/black)
Seal wells, sewers, ... in a radius of . m

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Required

Ok

Page 1 of 20

Work permit

Working document 1
Page 2/2

Required
Ok
Specific measures : fire hazard
Deploy fire brigade

Set ready fire hose

Extra foresee in .. mobile fire extinguishers class

Required
Ok
Specific measures : fall hazard
Place up railing (between 100 cm and 120 cm)

Place intermediate railing (between 40 cm and 50 cm)

Place baseboard (min. 15 cm from work surface)

Supplementary personal protection means to foresee by contractor

spatial view glasses / acid glasses
face screen
ear protection
fall protection
personal gas alarm
breathing protection
LEL
dust mask
O2
filter mask
CO
fresh air cap
H2S
compressed air mask
..........................
Required
Ok
Extra tests
Hoisting machines

Ladders

Electrical connections

Scaffolds

RATIFICATION
(To be complete by the distributing department)
Sort of the risks
extreme high
low
relative high
relative low
high
extreme low
Judged by (name and first name)
.................................................................
.................................................................
Signatures
Distributor
...............................
Requestor
..............................
...............................
...............................
Valid from
...............................
Valid till
...............................

PROLONGATION
From
..............................

(To be complete by the distributing department)

Till
Name and first name Signature
..............................
..............................
.............................
.

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 2 of 20

Registrati on VGM instructions

Working document 2

Undersigned, ...................................................., clarifies herewith that he took up

the safety prescriptions of Waterleau and the ruling safety prescriptions of RED
STRIPE BREWERY into the general safety plan and that he transferred the
prescriptions from the site regulations to his employees and subcontractors.
Explanation held on: .........................................................................
By:

.........................................................................

Following persons were present and have understood the explanation of the safety
prescriptions.
Name
...................................
...................................
...................................
...................................
...................................
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Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Function
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Signature
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Page 3 of 20

Registrati on Toolbox meeting

Work document 3

Undersigned, ......................................................., clarifies herewith that he dealed

with the beneath standing safety subjects and that he has explained those to a
sufficient extent so that his audience has understood.
Treated safety subjects:
1.
2.
3.
4.

.................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................

Explanation held on: .........................................................................

By:

.........................................................................

Following persons were present and have understood the explanation of the safety
prescriptions.
Name
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Function
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Signature
.................................
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Page 4 of 20

Incident report

Work document 4
Page 1/4

Incident number:
1.

General information
Date:

................................. Location:

Hour:

.................................

Person involved:

Name:
Address:
Telephone:

Employer:

Name:
Address:
Telephone:
Contact:

.................................

.........................................................
.........................................................
.........................................................
.........................................................

...................................................................
...................................................................
...................................................................
...................................................................
........................................................

Type of incident:
Accident with work delay
Accident without work delay
Almost-accident
Nursing

Incident with damage to property

Environmental incident
Serious risk
.....................................................

External aid:
Ambulance (called by: ........................................... )
............................................................................................................
2.

Short description of the incident

................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 5 of 20

Incident report
3

Cause of incident
Use of tools
Moving objects
Operating of machines
Handling with products
Mounting / demounting
Set-up of scaffold
Climbing / descending
Slipping / falling / stumbling
..................................................

4.

Managing of vehicles
Working on height
Welding / burning
Cleaning
Digging
Sampling
Tapping / spooling
Loosen connections

Circumstances of incident
Leakage
Fire / explosion
Environmental pollution
Transportation
Slipping / falling / stumbling
..................................................

5.

Work document 4
Page 2/4

Falling object
Electrical
Vandalism
Unsafe handling
Hoisting works

Injury
First aid:
..........................................................................................
Medical treatment:
..............................................................................
Kind of injury:
..............................................................................
Date of recovery (estimated): ..................................................................
Date of recovery (effective): ..................................................................
Remarks:
..................................................................

6.

Results of incident examination and analysis

................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 6 of 20

Incident report
7.

Work document 4
Page 3/4

Cause
Direct cause:
Lack of communication
Insufficient follow-up of rules and procedures
Insufficient safety signalizations
Ignoring or not-use of safety signalizations
Incorrect handling
Insufficient personal protection means
Not-use of personal protection means
Influence of alcohol or drugs
Unsuitable or failing tools or machines
Incorrect use of tools or machines
Work environment
Order en neatness
Access
External factors, thirds, weather conditions
............................................................................................................
Underlying cause:
Physical of mental inaptitude
Insufficient knowledge
Overburding
Insufficient motivation
Insufficient supervision
Insufficient policy
Insufficient planning or organisation
Insufficient procedures or prescriptions
Incorrect design or technique
Insufficient maintenance or inspection
............................................................................................................

8.

Conclusions and recommendations

................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 7 of 20

Incident report
9

Work document 4
Page 4/4

Witness
Name:
Address:

........................................................................................
........................................................................................
........................................................................................
Phone: ........................................................................................
Employer:
........................................................................................
Name:
Address:

........................................................................................
........................................................................................
........................................................................................
Phone: ........................................................................................
Employer:
........................................................................................
10.

Correction measures
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

11.

Signature
Person involved

....................................

Date:

.................

Prevention advisor

....................................

Date:

.................

Employer

....................................

Date:

.................

Coordinator

...................................

Date:

.................

Site supervisor

....................................

Date:

.................

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 8 of 20

Inspection checklist site

Inspection date :
Inspection by :
ORDER EN NEATNESS SITE
Are corridors, stairs passable and clean?
Is material storage safe?
Garbage
containers,
is
garbage
separated?
Lighting on the spot alright?
Sufficient ventilation?
Fire extinguishers accessible?
...
PERSONAL PROTECTION MEANS
Safety helmet (Art. 54-60)
Eye protection
Safety shoes
Protecting cloths, gloves
Falling protection, line (Art. 158)
Ear protection
Breathing protection
Prevention of falling (Art. 42 - Art. 269)
...
FIRST AID
Is First Aid box complete?
Is the content clean?
Stretcher present?
First Aid phone numbers are marked?
Blankets present?
...
ELECTRICITY
Electrical installation in good state?
Cabinet alright?
Extension leads, plugs, ... alright?
Earthing placed?
Electrical hand tools alright?
Glow equipment alright?
Generators alright?
Welding transformer alright?
...
ROADS, GROUNDS, TRAFIC
Boarding present?
Signalisation placed (day)?
Signalisation placed (night)?
Street lighting sufficient?
Road blockade reported?
Digging work barrier placed?
Band or turn wall necessary?
...

= Correct
Health- and safety plan
Site XXX

Version 1.0 d.d. 01-02-2006

Work document 5a
Contractor :
SUPPORT TOOLS
Gas storage in conformity with ARAB
313/318
Fire extinguisher on bottle rack?
Cylinders placed upright and fixed?
Control hand tools, machines, ...
- Condition
- Isolation
...
SCAFFOLDS, LADDERS, STAIRS
Is the scaffold checked?
Is the scaffold foreseen of a test sticker?
Is the scaffold free of materials?
Falling protection in good state?
Correct and safe implant
- Fixed
- Frame, ladder, securization present
- Ladder of sufficient length
...
LIGFTING TOOLS, HOIST INSTRUMENTS
Crane book present and alright?
Certificates hoisting material alright?
Indications readable present on: hoist,
straps,...
Visual alright?
Driver possesses a certificate?
...
CHEMICALS
Legend per product present?
Hazard labels correct?
Facilities at spills present?
Protection means present?
Storage in conformity with legislation?
Storage chemical trash present?
...

OTHER SAFETY POINTS

Propane-Butane storage in conformity?
Emergency road marked?
Work permit, instruction, alright?
Barrier on heights?
...

= Not acceptable

= Not applicable

Page 9 of 20

Inspection checklist - accommodation

Work document 5b

Inspection date :
Inspection by :
Contractor :
OFFICE, CANTEEN, DRESSING-, WASH-, OR SANITARY ROOMS
Is the building far enough of the road?
Is the interspace large enough?
Order and neatness around the accommodation correct?
Entrances safely accessible, lighting present?
Emergency doors foreseen of panic lock?
Pictogram emergency exit placed?
Fire extinguishers present (6 kg per 30 m)?
First aid box present?
Electrical heating with thermostatic regulation installed?
Electrical heating not covered?
Main current switch accessible?
Electrical installation in conformity?
...
HYGIENE
Office (floor, ashtray, litter bin, windows)
Canteen (tables, fridge, machines, ventilation, rubbish)
Wash- and dressing rooms (ventilation, wash and shower installation, sewage
connection)
Sanitary rooms (general neatness, sewage connection)
Warehouse (storage, paths, unload- and hoisting means)
...
CONTAINER FOR STORAGE MATERIAL
Safely accessible?
Electrical installation in conformity?
Are storage racks secured against falling over?
Contains container inflammable or explosive products?
Fire extinguisher present (6 kg per 30 m)?
...
WAREHOUSE
Has the warehouse a flat floor?
Safe access for persons and material?
Electrical installation in conformity?
Earthing present?
If warehouse is also work floor, is emergency exit present?
Fire extinguisher present (6 kg per 30 m)?
...
CONTAINER IN USE AS WORK SPACE
In conformity with local legislations?
Mechanical ventilation sufficient internal height - 180 cm?
Lighting present?
Fire extinguishers present (6 kg per 30 m)?
Space free from inflammable liquid and gas?
Clean floor?
Entrance good accessible?
...

= Correct
Health- and safety plan
Site XXX

Version 1.0 d.d. 01-02-2006

= Not acceptable

= Not applicable
Page 10 of 20

Inspection checklist activities general

Inspection date :
Inspection by :
DIGGING WORKS
Subterranean pipes localized and
marked?
Subterranean pipes out of use?
Passages held free?
Safe storage of material?
...

WORKS ON DIFFERENT LEVELS

Adapted passages above wells?
Adapted passages around wells?
Protection against ground collapse?
- calculation of stability
- protection against crumbling off
...
CONCRETE WORKS
Facilities for safe access of enclosed
places?
Use of stable (preferable metal)
formworkselements

...

PROBING
Use of efficient and certified material?
Data available on map?
Piping marked?
...
MANIPULATIONS
Installation emptied?
Valves closed and danger marked?
Hazardous products safe?
- efficient packed
- risk and hazard identification present
- prevention measures marked
Efficient inspection before use?

= Correct

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Work document 5c

Contractor :
DESTRUCTION WORKS

Persons protected against noise?

Persons and environment protected

against falling objects?

Inspection of hoisting machines and

accessories?

Loads rated by certified riggers?

Free or protected passages?

Openings enclosed with fix fence?

Orderly stock and carry away of

rubbish?

...
GROUND WATER TABLE PUMPS
Wells dimmed?
Give pipes stumbling danger?
...

HOISTING
Are all risks examinated?
- disconnect installation
- emptying installation
- free passages
- capacities and mobility
Are entrances enclosed?
Remain passages safe?
Is certified rigger present?
...
MACHINES / MATERIAL
Examination obliged installation tested?
All machines in good state?
Electrical installation in order?

...
ELECTRICITY
Installation tested for start-up?
Installation under tension marked?
Installation ready to start marked?
Interventions with personal padlock?
Signalisation PROHIBITED TO SWITCH?
...

= Not acceptable

= Not applicable

Page 11 of 20

Request for access on site after working

hours

Work document 6

Considering the identification of the persons who are on site, we ask you to fill
in this form for each worker to become access on site after the normal working
hours.
Employer:

Name:

Address:

Phone:
.
Fax: ..

Present superior:
Date:
From:
Till:

Number of persons:
Name
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................

Function
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Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Signature
.................................
.................................
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Page 12 of 20

Announcement of new employees

Work document 7

Considering the identification of persons who are on site, we ask you to fill in this form
for each worker to become access on site.
Employee

Name:
Address:
Phone:

Employer:

Name:
Address:
Phone:

.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.....................................................................
.......................
Fax: .......................

Direct superior:

.....................................................................

Personnel number:

.....................................................................

Date van employment:

Date of birth

..............................................................
..............................................................

Nationality
..............................................................
If EU EG citizen: E101 form in annex
Identity card number:
Social security number:

..............................................................
..............................................................

All data available by means of this form are kept under strict secrecy to protect
the private life. The data can be put at someones disposal after request of
official authority.

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 13 of 20

Formulation of remarks

Work document 8

Undersigned,
..............................................................
of
the
company, .............................................................., wants to declare a remark to the
site management. The site management obliges hisselfs to formulate an answer on
each remark that has been formulated via this organized way.
Remark
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Date: ..............................................................................................
Name and signature of the contractor:
For:

..............................................................................................

Results
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
Date: ..............................................................................................
Name and signature of site supervisor:
For:

..............................................................................................

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 14 of 20

Identification sheet for contractors

Working document 9
Page 1/3

Within the framework of the activities Construction of an effluent treatment plant on

the site of RED STRIPE BREWERY on location 214 Spanish Town Road, Kingston
Jamaica
the undersigned clarifies the principal
Waterleau Global Watertechnology NV.
Radioweg 18
B-3020 Herent
Belgium
that he has received the safety plan en that he will comply with it.
For the execution of the works the following identification data apply:
Firm:

Name:
Address:
Telephone:
VA.T..:
Date of order:
Sort of works:
Presumable

...........................................................................
...........................................................................
...........................................................................
............................... Fax: ............................
...........................................................................
................................................................
................................................................
................................................................
start date:
.........................................
end date:
.........................................

Number of foreseen workers on site:

Number of foreseen vehicles on site:
Notified body:
Name:
Address:
Phone :

..................
..................

.......................................................................................
.......................................................................................
.......................................................................................
...............................
Fax: ............................

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 15 of 20

Identification sheet for contractors

Working document 9
Page 2/3

Managing Director:
Name:
Phone:

.......................................................................................
...............................
Fax: ............................

Prevention advisor:
Name:
Phone:

.......................................................................................
...............................
Fax: ............................

Project engineer:
Name:
Phone:

.......................................................................................
...............................
Fax: ............................

Site supervisor:
Name:
Phone:

.......................................................................................
...............................
Fax: ............................

Safety expert on site:

Name:
.......................................................................................
Phone:
...............................
Fax: ............................
First aid (present on site):
Name:
.......................................................................................
Certificate:
.......................................................................................
Means:
.......................................................................................
Phone:
...............................
Fax: ............................
Insurer work accident:
Name:
.......................................................................................
Address:
.......................................................................................
.......................................................................................
Phone:
...............................
Fax: ............................

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 16 of 20

Identification sheet for contractors

Working document 9
Page 3/3

Medical officer:
Name:
.......................................................................................
Phone:
...............................
Fax: ............................
In case of external practice:
Name:
.......................................................................................
Address:
.......................................................................................
.......................................................................................
Phone:
...............................
Fax: .............................
Identification subcontractors:
Name:
.......................................................................................
Address:
.......................................................................................
.......................................................................................
Managing Director: ...........................................................................
Phone:
...............................
Fax: ............................
Identification subcontractors:
Name:
.......................................................................................
Address:
.......................................................................................
.......................................................................................
Managing Director: ...........................................................................
Phone:
...............................
Fax: ............................
Identification subcontractors:
Name:
.......................................................................................
Address:
.......................................................................................
.......................................................................................
Managing Director: ...........................................................................
Phone:
...............................
Fax: ............................
Signature:

.......................................................................................

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 17 of 20

Identification sheet for site material

Work document 10
Page 1/3

For the execution of the works, the responsible of following company declares that:
Firm:

Name:
Address:
Phone:

...........................................................................
...........................................................................
...........................................................................
............................... Fax: ..............................

Following site material is applied:

Name
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................
...................................

Identification
..................................
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..................................
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..................................
..................................
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..................................

Administrator
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................
.................................

For equipment wherefore an official test is obliged, the test certificates are present
on site and a copy has to be handed over to the site management.
For equipment which make use of chemical products (others then fuel), the product
information is available on site.

All site material that are apparatus, machines, installations, rooms, , are
found safe and are checked on safety and soundness on a regular base.
The users of the site material are sufficiently educated and possibly medical
followed up to use the material.

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 18 of 20

Identification sheet for site material

Are scaffolds used?

Work document 10
Page 2/3

: Yes

: No

Are hoisting machines used?

: Yes
Which :
Tirfort
Electrical hoist
Sky workers
Tele handler
Scissor lifts
Mobile crane
Lift truck
Front lift
Hang lift
Others: ........................................
Are these hoisting machines tested by a notified body?
: Yes

: No

: No

Which equipment / means are used?

Drill hammer & drill machines
Electrical shorten saws
Cut out saws
Grinding tools
Shoot hammers (pattern)
Table saws
Electrical groups
Compressors
Core drills
Others: ...................................
Which products are used?
Inflammable products and max. quantity on site
(White Spirit, degreaser, petrol, ...)
Product:
...............................................
...............................................
Chemical products and max. quantity on site
(Methyl-ethyl keton, glues, .......)
product :
...............................................
...............................................

quantity: ..........
quantity: ..........

quantity: ..........
quantity: ..........

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

Page 19 of 20

Identification sheet for site material

Work document 10
Page 3/3

Use of:
- Distiller (propane / butane)
If yes:
- check valve foreseen?
- fire extinguisher foreseen?
- storage of bottles?
- bottles identified?
- Oxy / acetylene distillers
If yes:
- check valve foreseen?
- fire extinguisher foreseen?
- storage of bottles?
- bottles identified?
- pressure gauges tested?
- Boilers (roofer)
If yes:
- check valve foreseen?
- fire extinguisher foreseen?
- storage of bottles?
- bottles identified?
- retention tank foreseen?
- instructions for personnel?

: Yes

Electrical equipment
- Use of extension lead
- Type H07RNF, H05RNF of CTMB
- Are they identified
(name of firm mentioned on cable or colour code)
- Sockets
Sealed (IP classified as required?)
Is this equipment tested by a notified body?

: No

: Yes
: Yes
: Yes
: Yes
: Yes

: No
: No
: No
: No
: No

: Yes
: Yes
: Yes
: Yes
: Yes
: Yes

: No
: No
: No
: No
: No
: No

: Yes
: Yes
: Yes
: Yes
: Yes
: Yes

: No
: No
: No
: No
: No
: No

: Yes
: Yes
: Yes

: No
: No
: No

: Yes
: Yes

: No
: No

Date:

.......................................................................................

Signature:

.......................................................................................

Indicate if applicable

Health- and safety plan

Site XXX

Version 1.0 d.d. 01-02-2006

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