(QSE 81001FM01)

AUTHORITY TO WORK PERMIT Job No.: ATW___

SECTION 1 – SCOPE OF WORK

Location:
Description of Work:

Start: (Date/Time) Finish: (Date/Time)

Contracting Firm Name: Contact Number:

SECTION 2 – TASK ANALYSIS (Must be completed and attached to ATW)

SECTION 3 – WORKER REGISTRATION (All persons listed below have been informed and kept updated of safe work requirements associated with
this task and shall abide by all such requirements.)
Name Name

SECTION 4 – WORK PERMIT ISSUE

This Authority to Work is issued for the above work and location ONLY, and ONLY on the condition that all required documentation (eg Job Safety Analyses) and
permits have been completed and the requirements thereof communicated to all involved persons.
Name Signature Contact Number
Accountable DPW Contract Coordinator:

DPW Area Supervisor:

Contractor in control of work:

Asbestos Register to be Checked for work involving puncturing / drilling of materials that may contain asbestos.
Confirm Check  Yes  Not Required
Please TICK the Work Permits that are required and attached to this authority to work:
 Working @ Hts  Confined Space  Hazardous Subs.  Complex Isolation  Lifting  Hot Work  Excavate  Other……………..
SECTION 5 – PERMIT HANDOVER
Contractor Handover Name Contact Number Signature Date / Time
Contractor taking control of task:
Sign off by original Contractor:
DPW Area Supervisor approving
contractor handover:
Area Supervisor Handover
DPW Area Supervisor taking
control of task:
Sign off by original DPW Area
Supervisor:

SECTION 6 – PERMIT COMPLETION

The work in the above location is complete. The work area/adjacent areas inspected and found safe. All workers in the area have been accounted for and
equipment has been returned to a safe operating condition. Tools used in the conduct of work are accounted for. If ALL of these conditions have been met, this
ATW is now cancelled.
Name Signature Date / Time
Accountable DPW Contract Coordinator:
DPW Area Supervisor:
Contractor in control of work:

Authority to Work Permit ALL COMPLETED PERMITS MUST BE RETURNED TO THE POINT OF ISSUE TO ENABLE 27th Jan 2008
Site – Version 0 CLOSURE OF THIS PERMIT AND FORWARDING FOR STORAGE Page 1 of 2
AUTHORITY TO WORK PERMIT - GUIDELINES

Recommended
ATW Issue Process

Definitions:
DP World person who has authority to issue an Authority to Work and is co-ordinating the work to be done, i.e.
DPW Contract Coordinator:
Process Owner
DP World person who has the responsibility to facilitate a safe working environment. Operations Shift Manager
DPW Area Supervisor:
Operations, Maintenance Shift Supervisors
Contractor supervisor in control of the work being undertaken. This is the person that will take responsibility for
Contractor in control of work:
ensuring that all requirements of the work permit are met and adhered to.

Notes:
1. The DPW Contract Coordinator and DPW Area Supervisor may be the same person.
2. All permits may be cross referenced to this Authority to Work rather than describe the same activity in several permits. This may only occur, on the
condition that all permits are kept together.
3. The Authority to Work is the overall controlling document for the work and is a formal authority to commence work.
4. The Authority to Work should be specific enough in scope to capture ALL required details. Accountable DPW Contract Coordinator must take caution
and increase vigilance when issuing an ATW over a period longer than 1 shift as work area changes may impact on the works without being
captured.

Authority to Work Permit ALL COMPLETED PERMITS MUST BE RETURNED TO THE POINT OF ISSUE TO ENABLE 27th Jan 2008
Site – Version 0 CLOSURE OF THIS PERMIT AND FORWARDING FOR STORAGE Page 2 of 2