Permit To Work Template | Editable & Free Download

Permit to work template

This permit to work template is a specialized tool that helps you control hazardous work activities, such as hot work, electrical maintenance, or confined space entry. It guides you through the process of risk assessment, authorization, and safe work completion, ensuring nothing is missed.

We developed this template specifically so safety managers and supervisors can avoid the critical gaps that might lead to incidents, drawing on lessons from events like the Piper Alpha disaster, where permit to work failures played a significant role. Use it to bring clarity and accountability to your worksite.

Related categories

Preview of the template

Permit Request

Work Activity Title

Specified high-risk work tasks covered to work by this permit

Start of Work

End of Work

Permit Request (On-site supervisor of the contractor/workers who have been engaged to perform the work)

This acknowledgement signifies a formal request to commence a work activity invoking one or more specified high-risk tasks. As the person requesting this permit, I hereby certify that

I have developed and/or reviewed the Risk Assessment and required Control Form/s relevant to this work activity.

I have consulted with relevant people to ensure that controls are adequate.

I am competent to coordinate this work activity in accordance with the attached Risk Assessment and Control Form/s.

I shall undertake to implement all planned and necessary controls to ensure the health and safety of those completing or impacted by the activity.

I shall ensure that the persons required to carry out the work are advised of and understand the requirements of the Risk Assessment and Control Form/s, and the Permit To Work / Access Instructions in Section 4 below.

I shall monitor hazards and control methods throughout the work activity.

I am requesting this Permit to be reviewed, registered and numbered by the Permit to Work Authorised Person.

Completion

Full Name and Signature of Supervisor

Person Engaging Contractor/Worker Review

This sign off is to signify that the PBPL person who engaged the contractor/worker has reviewed all documentation and provided comments

I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s and provided feedback to the contractor/workers.

I confirm as the person who engaged the contractor/worker, I will monitor the methods of work and the implementation of the proposed controls to ensure that standards for health and safety are being achieved throughout the works.

I have informed the relevant person/s for the area that the work is being performed in, the full scope of works to be completed by the contractor/workers and the processes developed for supervising and enforcing the works.

Completion

Full Name and Signature of Person Engaging Contractor/Worker

Authorization

This authorization signifes that the planning component of the work activity has been completed and that the work is authorized to commence in accordance with the risk assessment and required control forms. As the Permit to Work Authorized , i hereby certify:

I have reviewed the content of all related documents including the Risk Assessment and required Control Form/s.

I have registered this permit in the Permit To Work Register, allocated it a number and have written the number on all associated documents.

Complete

Full Name and Signature of Permit to Work Authorized Person

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Frequently asked questions

Who should use a permit to work template?

Safety officers, site managers, supervisors, and anyone responsible for authorizing hazardous work should use a permit to work template. It is essential for industries like construction, manufacturing, and energy where high-risk tasks are common.

When is it necessary to use a permit to work template?

Use a permit to work template whenever tasks involve significant hazards, such as hot work, electrical maintenance, confined space entry, or working at heights. It aids you in ensuring all safety protocols are followed and documented.

How do I customize a permit to work template for my site?

You can tailor the template by adding site-specific hazards, unique control measures, or custom authorization steps. This ensures the template fits your exact workflow and compliance requirements.

How does a permit to work template support compliance audits?

Auditors look for thorough, consistent records of permit to work processes. This template provides a structured, easy-to-follow record that demonstrates your commitment to regulatory compliance and best practices.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.