Work at Height Permit [PDF]

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WORK AT HEIGHT PERMIT PTW No



OLD PTW No



STEP-1 DESCRIPTION (By Contractor) PROJECT / PACKAGE NO:



AREA / LOCATION:



CONTRACTOR NAME:



RECEIVING AUTHORITY NAME; RELATED PERMITS NO’S:



START DATE



START TIME



EXPIRY DATE



EXPIRY TIME



NOTE – Permit is applicable any work at height above 1.8 meters from ground level. DESCRIPTION OF WORK TO BE PERFORMED:



TOOLS & EQUIPMENT TO BE USED:



MSRA NO;



DRAWING NO;



Receiving Authority Name;



Signature;



Mobile No;



Date / Time;



STEP-2 HAZARDS AND PPE / SAFETY EQUIPMENT IDENTIFIED ( Tick relevant boxes By Contractor)



HAZARDS / DANGERS               



Overhead Power Cables Moving machinery Manual handling Slips/trips/falls Wind, Fog, Rain etc. Fragile surface / Roof Uneven/fragile surface Excavation Confined Space Lack of visibility Danger of falling Men working below Overhead work Equipment condition Others



PPE / SAFETY EQUIPMENT IDENTIFIED         



        



Hand Gloves+Safety Glasses Hearing Protection Full body Harness (over 1.8 m ) Safety Shoes + Hard Hat Additional light Respiratory Protection Life line Radio Other (specify )



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WORK AT HEIGHT PERMIT STEP-3 PTW VERIFICATION Permit is Greenfield; Yes



Name



No



Closed out permit returned Yes No



Signature Date



Signature



Date



STEP-4 PRECAUTIONS TO BE TAKEN ( Tick relevant boxes By Contractor) YES NO



BEFORE STARTING:  Toolbox Talk to be conducted (appropriate languages )  Work area to be provided with safe access and egress  Work area Isolation barriers and signs to be in place  Persons are qualified/trained to undertake this work  Full body hardness to be used / inspected  Scaffolding in place / inspected  Ladder be set up at the right angle/inspected DURING WORK:  Access to the work area to remain restricted  All equipment to be turned off when work site left unattended  Suitable and Sufficient lighting to be provided in workspace  PPE to be worn at all times  Proper rest breaks to be observed  Plant / Equipment Operators to be certified



I have checked the permit and I understand the nature and extent of the work, and the precautions to be followed during work completion. Contractor’s Safety Officer:____________________________________Sign______________________Date_______________



STEP-5 PTW AUTHORIZATION AND ACCEPTANCE (CONTRACTOR) Issuing Authority:



Receiving Authority:



Signature:



Signature:



Date: Time:



Date: Time:



STEP-6 DAILY REVALIDATION ( R.A. INITIAL & TIME/DATE ) 2



3



4



5



STEP-7 DAILY EXTENDED HOURS( I.A. & R.A. INITIAL & 1 3 4 TIME/DATE ) 2



6



5



7



6



7



STEP-8 AFTER COMPLETION OF WORK ( Tick relevant boxes By Contractor) 



 



YES



NO



All areas had been made safe and all materials removed from site including good housekeeping All the equipment to be removed and area made safe All the PPE’S to be stored and made visual inspection



STEP-9 PTW CANCELLATION AUTHORITY (HATCH / CONTRACTOR) The Work Is Complete (Tick) The Work Is Incomplete



(Tick)



The work has been properly performed that all men have been withdrawn, and that the equipment, plant and electrical apparatus affected by the work have been left in a safe and clean condition. Issuing Authority:



Receiving Authority:



Signature:



Signature:



Date:



Date:



Time;



Time:



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