Safe Work Permit Emergency- CALL 911 Tracking Number:

Issued By: Phone #

Contractor Name: Phone #
Date: Time:
Location:
Work Description: Special Approvals:
No. of Workers: EH&S Audit- Auditor/Date:
GENERAL SECTION
ITEM S REVIEWED WITH SUPERVISOR (circle all that apply) Fall Protection requirements
1st aid/Injury reporting Eating/Smoking Areas Emergency Alarms/Evacuation
Safety Shower/Eyewash Break room/Restroom Areas High Pressure Liquids
Fire Extinguishers Fire Alarm System Lockout Job Entry/Roof Access Requirements
EXPOSURES TO PROTECT AGAINST (circle all that apply)
Hot Water Steam Heat Stress Chemical Name:
High Pressures Electrical Dust/Vapors/Fumes
Lead Paint Asbestos Flammable MSDS needed
Thermal Falls Corrosive materials
SAFETY EQUIPMENT (circle all that apply)
Hard Hat Gloves Welding PPE GFCI's
Safety Glasses Tyvek/Chem Suit Dust masks Chem. Spill kit
Goggles Rubber Boots Monitoring equip. Exhaust equipment
Face Shield Hearing Protection Fall Protection
JOB SITE REVIEW
Site inspected Surrounding area investigation
Hazards Evaluated
Drawings Reviewed Waiver of use of company equipment
Tools & Equipment Inspected
Barricades in Place
EXCAVATION SECTION
Call Before You Dig- contacts State/Local Jurisdictions- Contacts
Engineering/CAD contacts
Utilities marked Railroad contacts
Trench box requirements- size, location
EQUIPMENT OR LINE OPENING
Lines identified Equipment Purged and cleaned- inerting requirements
Valves closed, Lines drained, depressurized Original contents verified:
Lockout/Tagout completed PPE required
Secondary Isolation- Blind flange/blanks requirements Pipe stopper required
ELECTRICAL SECTION
Written procedures and requirements Lockout/Tagout requirements
Voltage check No electrical current- Before LOTO After LOTO
PPE- Gloves/Insulated tools/fire resistant clothing Fuse Removal requirements
Flash Suit- ref. NFPA 70E
HOT WORK SECTION
Security notified Fire blankets Purge gas req'd
Safety Observer Identified Isolate flammable liquids Cease adjacent work activities
Fire Extinguishers Risk of heat exposure to gaskets Harmful vapors emitted
Combustible Materials cleared to 35 ft. Ground lead
PERMIT CLOSE OUT
Job Completed- Yes / No Special Instructions
Return to Normal Use Yes / No Security notified
Injuries or near misses Yes / No Extended fire watch requirement
SIGNATURE- PROJECT LEADER
SIGNATURE- CONTRACTOR EMPLOYEE