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SUGGESTED ELEMENTS FOR A PERMIT-TO-WORK FORM

1. CONFINED SPACES PERMIT-TO-WORK 3. Job location 4. Plant identification 5. Description of work to be done 6. Hazards identified 7. Precautions necessary 2. Reference No:

8. Protective equipment available (checked and calibrated)

9. Signature to confirm precautions have been taken (by authorised person) Duration of permit: Time/Date:

10. Signature to confirm understanding of hazards and precautions (by persons carrying out the work) Time/Date: 11. Extension of permit if required. Signatures of those involved. Duration of permit: Time/Date:

12. Signature of person(s) carrying out the work to certify that work is completed. Signature of authorised person to certify that work is completed and that any plant is ready for recommissioning. Time/Date: 13. Signatures to certify that plant is satisfactorily recommissioned. Time/Date: