PERMIT TO WORK No:

Job: Contractor:

JMS No: Equipment, Area:

A) JOB ASSESSMENT
List down job step by step in details.
Potential Accidents / Risks /
Step Job Step Description What To Do To Prevent? Who do?
Hazards

B) OTHER PERMITS REQUIRED

1. Hot Works Yes / No Permit No: _____________________________________

2. Excavation / Break-In Yes / No Permit No: _____________________________________
3. One-Off Lifting Yes / No Permit No: _____________________________________
4. Overtime Work Yes / No Permit No: _____________________________________
5. Work At Height/ On Roof Yes / No Permit No: _____________________________________
6. Isolation Yes / No Permit No: _____________________________________
7. Isolation Yes / No Permit No: _____________________________________
8. Confined Space Entry Yes / No Permit No: _____________________________________
9. Live Working and Testing Yes / No Permit No: _____________________________________

C) OTHER PRECAUTIONS

D) COMMITMENT
We have understood and will obey the Scope of Work, Area Covered and Safety Aspects mentioned above.

Applicant Name (CM): Signature:

Contact No: From Date: Time: To Date: Time:

E) AUTHORISED PERSONNEL

Seconded Name (KiDE CM):

Issuer Name (EHS):
Contact No:
Contact No:
Signature:
Signature:
Date: Time:
Date: Time:

F) STOP WORKING Specify reason

G) Handover

The task has been completed, all relevant persons informed and the site has been rearranged tidily.
Applicant Signature: Date: Time:
Issuer Signature: Date: Time: