WORK PERMIT FORMAT Note: Permit is valid for 8 hrs OR Shift end which is max.
Note: Permit is valid for 8 hrs OR Shift end which is max. New Permit should be taken for continuing the activity next
day/Shift. (For Continuing shift, if working crew and accepter not changed then the permit can continue by extend
time on same permit
1 General or Cold Work Permit Permit No:
2. VALIDITY: 3. Name of Contractor 4. Job Location: 5. Type of Work: 6. Job Description:
Routine Non Routine
Date:
Start Time: 10. Precautions Checklist ( Tick in the applicable boxes).
End Time: Before Signing of Work Permit
7. Job Safety Analysis (Risk Assessment): Start work only after taking all the preventive actions Job site checked Identify the scope of work and associated risks
Sr. Status of Area Cordoned ( Barricaded) Ensure proper training and instruction
Job Steps Possible Hazard & Risks Preventive Action Responsibility
No Action Caution Board displayed Ensure a clear and easy route to emergency exits and
All tools checked & Fit to use. equipment.
1 Lifting tools certified
Wear goggles if your work poses a hazard to your eye
Workers induction given
GSL/Cont. Supervision provided
2 All PPE used Wear a breathing mask at all times, especially if: You deal with
dangerous or toxic chemicals or fumes
LOTO used Your workspace has poor ventilation
Your workspace has debris, dust, and other flying particles.
Fire extinguishers available and
readily attainable.
3
First Aid person & kit available
Note: General work checkpoints are common for all works & to be filled for general work as well as all
other works.
4
Examples of cold work activities that may require a permit include:
Painting – Painting activities may require a cold work permit to ensure that workers are protected from
exposure to hazardous chemicals and that proper ventilation and personal protective equipment (PPE) are
5 used.
Civil Works on groud Operating machinery such as forklifts or cranes can be hazardous if proper safety
protocols are not followed. A cold work permit may be required to ensure workers are trained and certified to
operate the equipment safely.
Erecting scaffolding – Scaffolding can be hazardous if not erected properly. A cold work permit may be required
6 to ensure that workers are trained to erect the scaffolding safely and that proper safety equipment is used.
Handling heavy objects – Handling heavy objects can lead to injuries if not done safely. A cold work permit
may be required to ensure that workers are trained to handle heavy objects properly and that proper lifting
techniques are used.
8. PPEs Required: Unloading of Hazardous Chemicals from Tankers:
Helmet Ear Plug Leather Gloves
Jacket Face Mask Others:
Safety Shoe Cotton Hand Gloves
Safety Goggle Rubber Hand Gloves
Note: Any other job specific PPE ( please Specify):
14. Permit Authorization:
9. Authorised Worker Details, Safety Pep Talk & 60 Seconds To Think Permit Initiator/
Permit Issuer (Contractor Safety Officer/
Permit Approver (Who is Supervising
Accepter (Work Work
Project Head)
S Physical 60 Seconds to Think (Accepter Need to Supervisor) (GSL Representative)
No Authorised workers Name Age Gender Trained Signature
Health Read and Tick each Line)
Y/N Name:
Should I be doing this work?
1
Do I know what needs to be done Y/N
and how to do it? Sign:
2
Have I identified all the possible risks Y/N
for this Activity? 15. Permit Acceptance ( In case of sub contractors)
3
Am I take all control measures Y/N I have been explained the content of this permit and all the risks associated with this job. I have been provided
against Hazards and risks? necessary PPE & basic Facilities. I shall be responsible for supervising the job. I assure that persons whose
4 names are recorded on this permit shall be working under me safely.
Do I gave/have all required PPE Y/N
to my team? Refer Column no.8 Name of the contractor Company: Sign:
5
Is my work going to create no Y/N
risk for the others? Date & Time:
6 Is each participant skilled and
able enough to work Y/N
in total safety? 17. Permit Closure:
7
Am I communicated all risks and Y/N Work completed & area cleaned Fire watch ensured for 1 hour continuously & next 1
hazards with team? Hazardous wastes disposed properly All the tools & equipments are placed in the standa
8
Resources and suitable Y/N All persons exited from confined space All LOTOs removed & Re-energisation procedure f
equipment available for do job? Fire watch Observation( Hot Work):
9
Does this job required to refer Y/N First 1 Hour continuous Observation: Next 1 Hours Intermittent observation:
any procedure for doing work?
10
If you didn’t tick one of these questions, don’t
start the work!
Safety Pep Talk Discussion Points: Note: Safey Officer shall ensure all the details of Permit Initiator/
Permit Issuer/ Issuing Authority (Contractor Permit Issuer/ Issuing Authority
workers, 60 Seconds to think, & Pep talk Details Accepter (Work
Safety Officer) (Contractor Safety Officer)
filled and implemented Supervisor)
Name:
Isolation Required? No yes If Yes, Fill Isolation details below.
Electrical Mechanical Hydraulic Pneumatic Sign:
Type of Isolation:
Thermal Chemical Name & Sign by Isolator:
