Prepared by: HSE Engr.

ELECTRICAL ISOLATION TESTING PERMIT - FORM - 33 Reviewed by: PM

Approved by: MD
Page 1 of 1

Permit No: Date:

Name of the sub contractor (if applicable):
Section I: (To be filled by authorized Receiver)
Location of the work (indicate level and grid no and enclose location sketch if required):

Work Description: Test Equipment:

Section II (Request for the permit) Permit Receiver to mark all boxes either with  (only for relevant ones) or mark as X
Description Y N NA Description Y N NA
Competent working crew has been deputed? LOTO Procedure in place and implemented?
Power supply switched off? Work area checked and free of combustibles?
Isolator switch locked and tagged? Work area identified and barricaded
Earthing available? Suitable warning Signs in place?
Testing Equipments calibrated, 3rd party certificates and sticker Attendance of testing team available and signed off
available?
Fire Extinguisher Training and Toolbox talk conducted? Housekeeping (before &after work)
Emergency Procedures & emergency contacts are
Standby (Buddy) available?
known to workers
Any other precautions taken?

Section III: (Request for the Permit - To be filled by authorized Receiver)

I request for an Electrical Isolation/Testing Permit for the above-mentioned work at the location specified above. I have personally
inspected the work place to ensure that the applicable precautions mentioned above have been complied with.

Name & Signature of the Authorized Receiver (Engineer /Foreman):

Name: Position: Signature: Date & Time:

Section IV: (Permit Approval - To be filled by authorized Issuer)
I have personally inspected the work spot and compliance of the relevant precautions given in section II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).

Name: Position: Signature: Date & Time:

Section V (Permit Verification – To be filled by Concerned HSE Officer)
I have personally verified the work spot and compliance of the relevant precautions given in section II of this permit.
The permit is valid from _ _ _ _ _ _ (hrs) to _ _ _ _ _ (hrs).

Name: Position: Signature: Date & Time:

Section VI: (Permit close out details)
(To be returned to the Site HSE office immediately after the completion of work or at the end of the shift)
Name: Position: Name: Position:

Signatures: Time: Signatures: Time:

Note:
1. Total 2 copies-Original at the work place, Second copy-with issuer; Close out permits (Original) to be submitted to Site HSE Office
2. The permit must be registered and a unique number to be given for each permit for follow up.
3. All safety precautions mentioned above must be in place prior to start of the electrical isolation.
4. Ensure there is no residual risk after completion of work.
5. This permit is valid only for the location mentioned in section I and for one day only.
6. Permit can be cancelled at any time if any violation observed.

IN THE EVENT OF AN EMERGENCY CONTACT SITE HSE OFFICE ON XXXXXXX