Permit to Work Form

Section 1: Details of works (Contractor to complete)

Company Name

Contact for Contractor

Phone Number

Description of work

Work Start Date Work Start Time

_______ / _______ / ______ _______________AM / PM

Proposed work end date Proposed Work

_______ / _______ / ______ _______________AM / PM
End Time

Work required to occur out of Work required to

hours (prior to 7am and after Yes / No Yes / No
occur at
5pm) weekends
(please circle) (please circle)

Issuer: (Print Name) Signature

Person carrying out the work Signature

(Print name)

Date permit issued

Copies to be lodged at / with □ MVRC Work location

□ MVRC Maintenance office
□ MVRC Risk and Compliance Manager

Section 2: Works involved

Yes No Comments

Hot Works involved

□ □
Excavation involved
□ □
Has the excavation area involved been
scanned for services □ □
Penetration involved
□ □
Electrical Installation involved
□ □
Gas Installation involved
□ □
Confined Spaces involved
□ □

MVRC Permit to Work Form V1

September 2016
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 Permit to Work Form
Use of Plant involved
□ □
Working at Heights involved (anything over 2
metres)
□ □

Section 3: Services / Areas affected

□ Mechanical lifts / escalators □ Roof □ Fuel Tanks

□ Fire systems □ Workshops □ Chemical storage
□ Water □ Gas isolation □ Electrical isolation

Section 4: Checklist / Permit conditions (MVRC Office use only)

Yes No Comments

Contractor approved
□ □ If not, do not sign PTW

Contractor has QR code – to provide

accreditation □ □ If not, do not sign PTW

All workers for the Contractor have a QR code

– to prove completion of online induction □ □ If not, do not sign PTW

Safe Work Method Statement received

□ □ If not, do not sign PTW

Risk assessment received

□ □ If not, do not sign PTW

Section 4: Permit Status (MVRC Office use only)

The work has been □ Concluded

□ Abandoned
□ Requires an extension
□ Barriers and warning signs remain if work not concluded
□ Tools removed
□ All persons have been withdrawn and warned to cease work in the area
covered by this permit
Permit closed / Authorisation to enter
withdrawn at: Date _______ / _______ / ______

Time _______________AM / PM

Section 5: MVRC Permit Number (MVRC Office use only)

MVRC Permit to Work Form V1

September 2016
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