PSM - SAFE WORK PERMIT

SECTION A: WORK DESCRIPTION SECTION B: WORK GROUP MEMBERS

Work Assigned to:
OPP Bldgs WO/Project # : Worker Initials
OPP Reno Print Names of Work Group
& Grounds
OPP
OPP Utility's Name:
Contractor, Off-Job
FAS
Permit issued for: Contractor Location of Work Area:
Hazardous Line Energized Electrical
Opening
Maintenance / Work
Management of
Other
PM Change Penn State Project Leader:
_________ MOC # : __________

____
Tools: Light Tig Hand
Drill Saw Welder Lift Other
s Welder Tools
Describe Specific Work To Be Done and Other Tools: Other Permits/Checklists/Approvals Required:
Hot Work* LOTO
Crane Hazardous
Excavation Confined
Line Opening*
Utility
Scissor/Work at Space Entry*
Heights Shutdow
Energized Electrical
n*
*Attachment required
Work*
SECTION C: POTENTIAL HAZARDS/RISKS & CONTROL MEASURES (check all appropriate boxes) Permit Writer completes with Equip. Operator at the job site.
(Check all appropriate Boxes & List Detail as necessary)
Accessibility Adjacent Lines Electrical Equipment Handling
Asbestos Thermal (> 550C (1310F)) Electrical Flash Excavations / Trenches
Toxic(s): Stored Energy Noise Underground Services
Fall/Slip/Trip Traffic including Fork Lifts &
Corrosive Pressure
Line Hazards Vehicles
Flammable Lifting Roof Access
Opening
Mechanic Overhead/
Inert Gas (Asphyxiant): Other Work in Area
al Heights
List Additional Potential Hazards/Risks:
Communicated to Work Group Std PPE (Hard Hat/Safety Glasses w/Sideshields/Safety
Scaffold Properly Constructed
Shoes) Fiberglass Ladder and
Communication devices: Goggles Boots (type):
Face Secured
Locks / Tags Addtl Hand PPE: Mechanical Ventilation
shield Barricades/Warning
GFCI Respirator (Type): Addtl Body PPE:
SCBA / Supplied Signs/Tags
Non Sparking Tools Full Harness w/lanyard LEL/O2 Meter
Air: Hearing Support Displaced/Detached
Fire Extinguisher Personal Welding Face Shield
Equipment
Protection Operator Equipment
Chemical Resistant Boots Apron Informed Water Supply - Fire Watch
Building/Facility Mgr.
Tyvek suit/Rainsuit Welding Shield
Informed
✘ List Additional Safety PPE/Equipment/Instructions needed:

SECTION D: SPECIFIC SAFETY REQUIREMENTS Permit Writer completes with Equip. Operator at the job site.
Yes N/A Yes N/A
Work Site Inspected & Acceptable To Begin Work…………. Safety Watch Required, Name(s)……………………
Adjacent Equipment Safe……………………………………… Safe Work Procedures Reviewed……………………
All Personnel in Area Notified of Work……………………….. Work Area Barricaded & Signage/Tags in Place…..
Know Location of Fire Extinguishers / Alarms………………. Work group members Approved Entrants…....….…
Know Location of Eye Wash / Safety Shower……………….. Is an MOC needed for this work?...............................
Section Not Applicable Lockout / Tag Out (LOTO) Yes N/A
Number of Owner Locks Used: Yes N/A All Energy Sources Locked & Tagged By All Exposed….
Equipment Specific LOTO Procedure or Sheet Complete & Attached Stored Energy Dissipated and/or Restrained……..
Affected Equipment Shutdown By Normal Operations Operator Attempted Restart of All Equipment With Permit Writer……
Section Not Applicable Line Breaking / Equipment Opening Not For Extremely Hazardous Materials
Line / Equipment Drained / Purged / Cleaned………………. Required Splash Guards In Place……………………
Required Line Blinds/Blanks Installed……………………….. Out of Line of Fire & Special PPE Worn……………..
Heat Trace LOTO………………………………………………… Line Temperature ______________ F
SECTION E: APPROVAL TO WORK Permit Writer and Equip. Operator complete (other workers sign in Section B).
We have reviewed Sections A, B, C, D. The work group is properly equipped and has a common understanding of the scope and permit requirements.
Signature Date Time (24 Hr)
Permit Writer

Equipment Operator
Facility/Building Rep.
Note: Copy of Permit must be kept at the worksite until closed and is only valid for a maximum of 12 hours from time approved.
SECTION F: CLOSING PERMIT Equip. Operator completes with Permit Writer
Yes No N/A Yes No N/A
Job Status Communicated Safety Devices/Guards Reinstalled Check if any EHS problems were
encountered during the job and list
Job Area Cleaned of Debris All Workers(s) Lock(s) Removed them on the back of this form.
We have personally inspected the work site and accept that this permit is closed.
Signature Date Time (24 Hr)
Permit Writer

Equipment Operator
Original copy at Worksite Copy to Equipment Operator and Project Leader/Facility Mgr.
PSM-SF-UN-001 (02-2015 rev5)