TN N V

GIY PHI HP CHO PHP

S: //

1. Cp cho:
1.1. Ngi lnh o cng vic (nu c):.............................................................................................................................
1.2. Ngi ch huy trc tip:...................................................................................................................Bc AT/5
1.3. Nhn vin n v cng tc (ghi s lung ngi):..........................................................................................................
Thuc (Cng ty, Phn xng,..)...........................................................................................................................................
1.4. a im cng tc:.....................................................................................................................................................
1.5. Ni dung cng tc:.....................................................................................................................................................
1.6. Thi gian theo k hoch:
- Bt u cng vic:......gi ......pht, ngy....../...../.........
- Kt thc cng vic:......gi ......pht, ngy....../....../........
1.7. iu kin v an ton in tin hnh cng vic (ghi r ct in mt phn hay hon ton thit b, ng dy, on
ng dy):........................................................................................................................................................................
..........................................................................................................................................................................................
1.8. Cc n v QLVH khc c lin quan n th tc cho php vo lm vic:..................................................................
..........................................................................................................................................................................................
1.9. Ngi thc hin BPAT ca n v QLVH cp Giy phi hp cho php ngi cho php ca n v QLVH cp
Phiu cng tc lm th tc cho php lm vic: ................................................. Chc danh:.............................................
Gi phi hp cho php cp ngy ...../...../...... . Ngi cp (k v ghi h, tn): .................................................................
2. Bin php an ton phi hp cho php:
2.1. Nhng thit b, ng dy, on ng dy ct in:...........................................................................................
..........................................................................................................................................................................................
2.2. tip t ti cc v tr:.............................................................................................................................................
2.3. Cc bin php an ton khc:.......................................................................................................................................
..........................................................................................................................................................................................
2.4. Phm vi c php lm vic:.....................................................................................................................................
..........................................................................................................................................................................................
2.5. Cnh bo, ch dn cn thit:.......................................................................................................................................
2.6. Ngi ch huy trc tip v ngi cho php c php lm th tc cho php lm vic i vi phn thit b ca
...., lc ...gi ...pht, ngy ..../.../....
Ngi thc hin bin php an ton phi hp cho php (k v ghi h, tn):...................................................................
3. Tip nhn phn thit b ca n v c lin quan n ni lm vic:
3.1. kim tra nhng bin php an ton ti hin trng:...............................................................................................
..........................................................................................................................................................................................
3.2. n v cng tc lm bin php an ton:.....................................................................................................................
Ngi ch huy trc tip nhn Giy phi hp cho php lc ...gi ... pht, ngy ...../...../.........
Ngi ch huy trc tip (k v ghi h, tn): .....................................................................................................................
Ngi gim st an ton in (k v ghi h, tn-nu c):....................................................................................................
4. Tr li cho n v QLVH phn thit b khng cn lin quan n cng vic:
4.1. Thi gian, ni dung giao, nhn:..................................................................................................................................
..........................................................................................................................................................................................
4.2. H tn ngi nhn ... chc danh n v..............................................
4.3. thng bo vi n v QLVH cp phiu cng tc, lc gi ..pht, ngy //
H, tn ngi nhn chc danh.......................................................................
4.4. Ngi ch huy trc tip (k v ghi h, tn):..................................................................................................................
kim tra hon thnh phiu, ngy ...... /...... /......
Ngi cp Giy phi hp cho php (k v ghi h, tn):...................................................................................................