WORK AUTHORIZATION PERMIT FORM

NAME OF REQUESTOR: PERMIT NUMBER:

POSITION: START DATE:
DATE REQUESTED: END DATE :
PART I: TO BE COMPLETED BY THE REQUESTOR
Work location: ____________________________________________________________________________________________________
PART II. To be completed by the qualified person doing the work: (Use another sheet if necessary)
III. Nature of work
Installation and maintenance of machines / Other please specify:
Building repair or maintenance ________________________
equipment activities, Trimming of trees and ________________________
Delivery and hauling of materials Grass cutting) ________________________
Surveying / Sampling / Testing activities Construction / Civil works __
IV. PPE requirement
Others please specify:
Hard hat Safety googles ________________________
Face mask / Dust mask Ear plug ______
V. Safety equipment
Safety warning signs LOTO equipment First aid kit
VI. Hazards VII. Safety precaution
Note: If the hazard is present in the area check yes and provide ncessary safety control measures
Failure to accomplish work permit Y N N/A Define work activitiees Y N N/A
Failure to conduct CPR & HIRAC Y N N/A Conduct CPR and HIRAC Y N N/A
Failure to attend safety orientation Y N N/A Attend safety orientation Y N N/A
Failure to turnover work permit on the Inform and monitor the validity and
Y N N/A Y N N/A
next shift cancllation of work permit
Communication failure during the Communicate the risk assessment
Y N N/A Y N N/A
application of work permit (HIRAC)

Wrong type of permit used Y N N/A Only authorized worker shall process Y N N/A
work permit
VIII. Separate permit required for the work
Note: Put a check on the box for the require work permit application.
Work authorization permit form Excavation of trenches & holes
Confined space permit form Hot work permit form
Heavy equipment permit form Working at height permit form
Work on, over, or near water permit form Electrical safety permit form
Safe use of heavy equipment permit form Others pls. specify _____________________
XI. Approval(s) to perform the work

I hereby acknowledge receipt of this permit having inspected the above safety precautions. I am satisfied that the precautions taken
are adequate and I accept responsibility for undertaking the work specified above in a safe manner. I declare that neither myself, nor
those persons within my control, will not attempt any other task than that specified above.

Prepared by:

Printed Name: ________________________________ Signed: _________________ Date: ____________

(Porject in charge / Team Leader)
Approved by:
Printed Name: _____________________________________ Signed: _________________ Date: ____________
(Contractor Safety Officer)
Note by: _______________________________ Signed: _________________ Date: ____________
(Contractor Project Manager)
Note by: _______________________________ Signed: _________________ Date: ____________
(MWPV - EW Project Manager)
Arc flash clothing Safety Glasses/Goggles Hard hat
Arc rated face shield Ear plugs Leather Gloves
Voltage-rated Tools Hard hat Flashsuit
Voltage rated shoes Voltage rate gloves Others

LOTO application Safety Watch Notify affected workers

Equipment / Machine work De energized
High voltage exceeds 650 volts Other pls specify
Low voltage exceeds 50V or 120v ______________