HSE DEPARTMENT

PERMIT TO WORK HSE-001

PROJECT: CADANGAN PEMBANGUNAN KOMPLEKS KEJIRANAN DAN
KEMUDAHAN LAIN
DATE:
DI ATAS PT12615, SELUAS 2.52 EKAR DI PRESINT 18, PUTRAJAYA
UNTUK PERBADANAN PUTRAJAYA

Job: Date
Start End

Person In charge No.Tel

Request by
Supervisor

Position Engineer

Contractor Safety Officer

Competent
Date
Person

Location Others:

Total of Workers
]

1.0 Job Description

1.2 Job Safety Analysis (JSA) / HIRARC provided

2.0 Machine or equipment will be used Total of Machinery

1
 HSE DEPARTMENT
PERMIT TO WORK HSE-001
PROJECT: CADANGAN PEMBANGUNAN KOMPLEKS KEJIRANAN DAN
KEMUDAHAN LAIN
DATE:
DI ATAS PT12615, SELUAS 2.52 EKAR DI PRESINT 18, PUTRAJAYA
UNTUK PERBADANAN PUTRAJAYA

3.0 Proposed Safety Precaution to be implemented:

Elimination / Substitution Isolation Engineering Control Administrative Control PPE
Remarks :

4.0 Comments by Safety & Health Officer/ Supervisor :

Note: This “Permit to Work” (PTW) form shall be submitted to Safety & Health Officer/Supervisor
for approval within 24 hours before start work. This PTW is valid for a working period herein stated in this
permit. If the extension of working period is required, please request for new PTW.

Requested by: Approved by Safety & Health Officer/Supervisor

Name: Name:
Position: Position:
Date: Date:
Time: Time:

2
 HSE DEPARTMENT
PERMIT TO WORK HSE-001
PROJECT: CADANGAN PEMBANGUNAN KOMPLEKS KEJIRANAN DAN
KEMUDAHAN LAIN
DATE:
DI ATAS PT12615, SELUAS 2.52 EKAR DI PRESINT 18, PUTRAJAYA
UNTUK PERBADANAN PUTRAJAYA

Hot Work/Confine Space/Working at Height/Excavation/Others Dangerous Activities

Name of Sub-Contractor :…………………………………………………………………………………………..

Name of Sub-Contractor’s Supervisor :……………………………………………………………………………

Type of Work :………………………………………………………………………………………………………..

Location of Work :…………………………………………………………………………………………………….

Validity of Permit From :…………………………………to………………………………………………………..

(Date / Time) (Date / Time)

Please tick if Acknowledge By

Yes (Safety & Health Officer/Supervisor)

1. Have the subcontractor and his employees

Been briefed on Site Safety Rules? …………………………………………

2. Have the subcontractor’s tools and equipment

Been inspected? …………………………………………

3. Have the subcontractor’s personal protective

Equipment been checked? …………………………………………

4. Is the HIRARC available?

…………………………………………

This permit is issued by:

………………………….. ……………………………. ………………………………..

Signature Name Date / Time

This permit is received on behalf of the subcontractor by:

………………………….. …………………………….. …………………………………

Signature Name Date / Time

Permit To Work close by:

…………………………… …………………………….. …………………………………..

Signature Name Date / Time
3
 HSE DEPARTMENT
PERMIT TO WORK HSE-001
PROJECT: CADANGAN PEMBANGUNAN KOMPLEKS KEJIRANAN DAN
KEMUDAHAN LAIN
DATE:
DI ATAS PT12615, SELUAS 2.52 EKAR DI PRESINT 18, PUTRAJAYA
UNTUK PERBADANAN PUTRAJAYA