Document No.

SH-F43
ALLIED ENGINEERING CONSTRUCTION SDN. BHD.
Rev. No. 00
PTW No.
PERMIT TO WORK (PTW) Frequency As required
Contractor Company Name:
Applicant's Name: Sign:
Application Date: Date start work: Date of Completion:
Time Start: AM / PM Time Finish: AM / PM Contact No.:
Location :
BRIEF DESCRIPTION OF WORK
Description:
SOP/SWMS/WI & JSA/JHA reviewed
or referenced: YES / NO (state title):
NATURE OF HAZARDOUS WORK TO BE DONE
Machine
Welding/Cutting/Grinding Crane Operation Confined Space
Relocation
Major Electrical Work Scaffolding/Ladder Major Excavation/Trenching Lifting
Wall/Concrete Demolishing Working at Height (All Trades) Others (specify):
TYPE OF HAZARDS ASSOCIATED WITH THIS PTW
Slipping / Tripping Pinch points Flying Particles Visibility
Falling from Height Extreme Temperatures Low Oxygen Respiratory
Falling Objects Operations Heavy Lifting High Noise level
Struck by Explosive gas/Vapors Exertion Oxygen Percentage
Isolation (lone
Caught Between Chemical/Corrosive Substance Poisonous gas/Vapors
work)
Contacting Energy Pressure Energy Source (Electrical) Insufficient Lighting
PERSONAL PROTECTIVE EQUIPMENT (PPE) THAT MUST BE WORN
Goggles Safety Shoes Hard hat Harness
Breathing Apparatus (SCBA) Face Shields/Eye protection Rubber boots Ear plug
Mask Fall protection (fall arrestor) Gloves Respirator
Safety Vest Others please specify:
PLEASE COMPLY TO THE SAFETY REQUIREMENTS BELOW
Provide fire extinguisher Remove combustible materials Portable gas detector

No entry signage Certificate/permit/competency required Barricade work area

Adequate ventilation Needs contractors/project engineer Supervision Safety signage
Buddy System Construction/renovation in progress & pic/signage or stand Standby person
“No Smoking” Signage Others (specify): Access/Escape route
ASSESSEMENT & APPROVAL BEFORE START OF WORK
I am satisfied that the work has been safely planned.
AEC Site Manager/Representative (Name, Sign & Date): S&H Representative (Name, Sign & Date):

PERMIT SUSPENSION CLOSE OUT DETAILS

Reason for Permit Suspension: Name:

Suspended by (Name, Dept., Sign & Date): Date:

Safety systems have been uninhibited. In the case of Isolation full function has been restored.
Site Manager or Supervisor/HSE Representative: Sign:
1. After work completed, this permit must be returned to AEC Responsible Person for filing.
2. Non-compliance to the above will result in issuance of STOP WORK ORDER and FULL liability on the Person In Charge and Suppliers.
3. In case of emergency/accident/fire please contact Emergency Response Team immediately.
 Details of Workers
Name Nationality I.C/Passport No.

Remarks: