GENERAL WORK PERMIT

Permit SR.No.

To be filled in by Job Supervisor/ Engineer

Permit Valid from .. To ., if Job supervisor changed then their signature should be incorporated in the format
Job Executor

Name:

Sig.:

Date:

Department:

Time:

Description of work

Equipment No
Location
A
Action Taken by Executor : Please write Yes or No in the box provided.
Sr.No.
1
2
3
4
5
6
7
8
9
B
Sr.No.
1
2
3
4
C
Sr.No.
1
2
3
4
5

Hazard Identification

Yes/No

Remarks

Electrical
Confined area
Height Work
Hot Work
Excavation work
Mobile Crane
Compressed Air
Hydraulics
Any Other

PPE Required : Please write Yes or No in the box provided.

PPE

Yes / No

Sr.No.

PPE

5
6
7
8

Hand Gloves
Apron & Leg Guard
Heat Resistance suit
Any Other

Full Body Harness

Ear Plug
Goggle / Face shield
Dust Mask

Yes / No

Permits Required : Please write Yes or No in the box provided.

Safety Checks for compliance

Yes/No

If Yes,

Permit
No.

Remarks

Is Electrical Work Permit Required ?

Is Confined area permit required ?
Is Height Work Permit Required ?
Is Hot Work Permit Required ?
Is Excavation work permit required ?
Name of Concerned
Process Engineer

Is Process Isolation required ?

If YES, take clearance form process Dept.

Permit Issuer

Name

Signature

Date

Signature & Date

Time

Concerned Engineer
Concerned SH

Acceptance: To be completed by the person who will carry out the job. Then to be handed back to issuing person.
I understand the work which is to be carried out and the method of work to be used to ensure
that it is carried out safely .
No work will be carried out other than the work authorized by this permit
Extension / Transfer of permit
Date
Signature
Job Supervisor
Concerned Engr.
Concerned SH

Date

Signature

Signature:
Date:
(Job Supervisor/Contractor )

All checks reviewed & found OK to extend permit

Date
Signature Date
Signature
Date

Time:

Remarks
Signature

The above work is completed. Man power deployed is removed from the

Completion: working site.

Signature:
Date:
(Job Supervisor/Contractor )

Time:

1. This permit Applies only to work in the location described.

Note :

2. This permit only applies to the person to whom it is issued. If work has to be continued by someone else, this permit must be returned to issuer for cancellation
and another permit issued.

Copy : (1) Job Sup./Contractor (2) Safety Office, (3) Office Record ( Retention Period 7 days)