TAKE 5 AND DAILY WORK PARTY Date

STATEMENT OF UNDERSTANDING PTW Ref. No.

Section 1.0: TASK FOR THE DAY/SHIFT BASED ON THE PTW (Permit Receiver)
(State area, location, site, activity to do, unit no, define if work party is with contractor or organic only)

Section 2.0: TAKE 5 GUIDE (WORK PARTY)

BEFORE YOU START THE TASK
Assess the task that you will perform.
You and your team responsible for the work are all
aware of the task that you will be doing?
Is my team aware of the hazards associated in my
task with the controls to be implemented?
DURING THE TASK
Y N Reassess the task frequently.
Stick to your plan, task analysis and work
instruction. Don’t take shortcuts.
Is the task your performing is going planned?
Ensure that the safe condition of your work area is
not changed.
Are the safe conditions in your work area the
same?
AFTER COMPLETING THE TASK
Y N Observe the work area, people and surroundings. Y N
Check and ensure that the task has been performed
completely as planned.
Is there any work outstanding?
Ensure that the work area is clean before leaving.
Is my work area clean and tidy?

Ensure that you and your team is confident that

Are all required TRA, PTW, clearances and LOTO Did you and your team perform safely and well until
they feel safe while doing the task.
are in place to undertake the task? completion to the assigned task?
You and your team feel safe while doing the task?

Ensure that the controls are in place and working

Have you and the team identified the controls that during the task. Check the work area for any new hazards after the task.
will prevent damage to the environment, people The environment, your team, other people and Are there any new hazards identified in the work area
and the facility? community are protected with your implemented after the work completion?
controls.

Are we prepared if there is an emergency? Did my Ensure that the nearby activity does not affect your Were others around you working in a responsible
team understood their role in emergency work. manner and did not add hazards in your work area
situations? Are others around you working responsibly? before leaving the area?

Is my team fit to perform the work and provided

No unexpected or new hazards entered and Can any improvements be made? To perform the work
with appropriate and good condition PPEs to
present in the work area during the work? better and safer.
perform the task?

If answered “no” from one of the questions. Discuss these improvements with the Permit Issuer.
Are the tools and equipment to be used in the task
Take a pause, suspend the work and inform the Discuss with the team.
are inspected and color coded?
Permit Issuer as soon as possible.

Section 2.0: TOOLBOX TALK CONTENTS (Permit Receiver)

Topics discussed
and Actions to be
Taken:

Section 3.0: DAILY COMMITMENT TO WORKING SAFELY (Work Party) Use additional sheets as necessary.
The requirements for the safest performance of this job have been explained to us from the scope; individual responsibilities; hazards and its controls; worksite
precautions and the PPEs to wear. Having clearly understood the requirements, we hereby give our unconditional commitment to comply and adhere to them so
we can complete our job in the safest and most efficient manner.
It is also our responsibility to immediately report any incident to our Supervisor and/or to the Control Room.
SIGN ON SIGN OFF
WORK PARTY DESIGNATION
Date and Time Signature Date and Time Signature

9
Section 5.0: COMMENCEMENT OF WORK (Permit Issuer, Permit Receiver)
The permit conditions and safety precautions are to be followed in completing the work.
Section 4.0: WORK PARTY CLEARANCE (Permit Receiver)

As the Permit Receiver and the Supervisor of this Work Party, I declare that the above listed personnel have had their toolbox talk; are aware of the scope of the job;
individual responsibilities; the workplace hazards and its controls; the precautions to be taken and the PPE to wear.

Name Signature Date Time

COA-SHE-001-F053
Rev.00 / 2021.01.30