PTW No:

PERMIT TO WORK
NO WORK THAT IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY

SECTION 1 - REQUISITION COLD WORK PERMIT ELECTRICAL PERMIT

APPLICANT NAME : ...................................... DEPARTMENT/COMPANY : ......................................... Requisition Expected Completion
LOCATION/FACILITY : ...................................... AREA/UNIT : ......................................... Date : ...................... Date : .........................
EQUIPMENT NO. : ......................................
WORK DESCRIPTION :

SECTION 2 - POTENTIAL HAZARDS

□ Drilling □ Saw / Cold cut □ Hand tools only □ Flame cutting □ Grinding
□ Electrical tools □ Welding □ Vehicle □ Scaffolding □ Power brushing
□ Lifting □ Working at high □ Crane □ Hydro jetting □ Generator / Compressor
□ Pressure test □ Excavating □ Chemical □ Electronic device □ Loading / Unloading
SECTION 3 - WORKSITE PREPARATION / PRECAUTION
□ Tagging □ Secure tools against falling □ Barricade and warning sign
□ Equipment isolation □ Flushed with water □ Others: ..........................................
□ Valve isolated □ Contact maintenance before start work
□ Scaffold erected and safe to be used □ Contact maintenance once completed
SECTION 4 - PERSONAL PROTECTIVE EQUIPMENT
Head, Eye & Face Hearing Hand Foot Body
□ Helmet □ Ear plug □ Cotton glove □ Safety shoes / boot □ Coverall
□ Safety glass □ Ear muff □ Leather glove □ Safety rain boot □ Chemical suit
□ Goggle □ Rubber glove □ Electrical shoes / boot □ Leather / Rubber apron
□ Face / Welding shield □ Chemical glove □ Life vest
SECTION 5 - SUPPORTING CERTIFICATE DOCUMENT
□ Electrical isolation cert. no : ............................ □ Excavation cert. no : ............................................ □ Road construction cert. no : .........................
□ Job Safety Analysis (JSA) □ Drawing no : ........................................................ □ Others : ........................................................
SECTION 6 - JOINT VISIT BEFORE WORK START / APPROVAL
I / We have personally checked the area and the equipment to be worked on and am satisfied the work requested can be carried out safely.
RECEIVING AUTHORITY / REPRESENTATIVE APPROVING AUTHORITY / REPRESENTATIVE

Name : ............................................................... Name : ...............................................................

Designation : ..................................................... Designation : .....................................................
Signature : ......................................................... Signature : .........................................................

AGREED AND SGNED BY RECEIVING AUTHORITY APPROVING AUTHORITY AGREEMENT BY WORK LEADER

Name : ................................................................. Name : ................................................................. Name : .................................................................

Signature : ........................................................... Signature : ........................................................... Signature : ...........................................................
Date : ............................... Time : ........................ Date : ............................... Time : ........................ Date : ............................... Time : ........................

SECTION 7 - REVALIDATION
DATE RECEIVING AUTHORITY APPROVING AUTHORITY AA REPRESENTATIVE WORK LEADER

SECTION 8 - HANDBACK
□ Incomplete hand back (equipment status, reason for hand back, etc) □ Work completed □ Housekeeping completed
RECEIVING AUTHORITY ACCEPTED BY APPROVING AUTHORITY

Name : ...................................................... Date : ................................ Name : ...................................................... Date : ................................

Signature : ................................................ Time : ................................ Signature : ................................................ Time : ................................

STOP WORK AND EVACUATE AREA ON HEARING OF EMERGENCY ALARM

Distribution - Original : Display at worksite Copy No. 1 : Guard House (HSE) Copy No. 2 : Receiving Authority