Form-037

Electrical Work Permit

Rev. : AD Date: 02 09 2020

Name of Project Date

Equipment Name & ID No.
Exact Location

Description of Equipment:
Permit No:

Description of Work

Additional Information
Is this a normal job occurrence? If No (provide details why it needs to be
Yes / No done)

Instructed by :

Name: _____________________ FAST Dept:____________________________

Partner’s Pre Job Checklist valid and
available?
Client Representative

Hazards Noted
 Nil noted  Electricity  Immediate vicinity
 Gas  Working at heights  Solids
 Liquids  Hot surfaces  Stored energy
 Stored Energy  Others

Permits
 None required  Excavation Permit  HV Access Permit
 Hot Work Permit  Live Voltage  Others
 Confined Space Permit  Roof Access Permit

Protective Equipment
 Canister Type
 Standard Clothing  Gloves _______ (Type)
Respirators
 Hot Work Clothing  Eye & Face Protection  Rubber Boots
 Face Shield  Hearing Protection  Safety Harness
 Helmet  SCBA  PVC Jacket
 PVC Pants  Others

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 Form-037
Electrical Work Permit
Rev. : AD Date: 02 09 2020

Isolations
 Nil required  As indicated below
 As per attached isolation list  Own isolation as required with personal log & tag
Check Isolation De-Isolation
Item Description Method
for dead Intl Date Time Intl Date Time
/ / : / / :
/ / : / / :
/ / : / / :
/ / : / / :
/ / : / / :
/ / : / / :

The building or plant item described above is in my opinion in a safe condition for the job to be
done provided all the conditions above are fully observed. These conditions have been discussed
with, & understood by, the persons involved.

Authorized Person
Name Sign Date Time Valid Until Time
/ / : / / :

Acceptance and Return

(This Permit is only valid when all above parts have been completed)
Responsible Person/s obtaining Permit to Work:
I have read this Permit to Work and am aware of the hazards and precautions need to adopt.
I undertake to comply with these. Should there be a change in conditions which introduce
new hazards, I, or the work party will stop work and notify the Authorized Person. Work will
only proceed when it is safe to do so. I shall vacate area on request or alarm. I shall not
interfere with on-line equipment.
Name Sign Dept/Partner Date Time Completed
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
Responsible Person as signed on for __________Others. (All must attach locks/personal
danger tags at each isolation point.)

Page 2 of 4 M3-FST-FOR-HSE00-GEN-000037
 Form-037
Electrical Work Permit
Rev. : AD Date: 02 09 2020

Responsible person or persons returning over plant to owner:

I or my work party has withdrawn from the job. Unless otherwise mentioned or indicated all
tools, materials and equipment from the immediate vicinity of the work area, have been
removed, all flange guards replaced, all Personal Danger tags and/or locks removed and the
area cleaned.
Name Sign Dept/Partner Date Time Completed
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No

Job Completed
The equipment or item is safe to return to normal service. This Permit to Work is now withdrawn.

Authorized Person
Name Sign Dept/ Partner Date Time
/ / :

Permit to Work Extension

The building, or machine or item described above is in my opinion in a safe condition for the job to be done
provided all the conditions above are fully observed. These conditions have been discussed with, & understood by,
the persons involved.
Authorization
Name Sign Dept/ Partner Date Time
/ / :

Page 3 of 4 M3-FST-FOR-HSE00-GEN-000037
 Form-037
Electrical Work Permit
Rev. : AD Date: 02 09 2020

Acceptance & Return

(This Permit is only valid and & when all conditions are complied with)
Responsible Person or Persons obtaining Permit to Work:-
I have read this Permit to Work and have had the hazards and precautions explained to me. I
undertake to comply with these provisions. Should there be a change in conditions and
where new hazards are introduced new hazards, I, or the work party will stop work and notify
the Authorized Person. Work will only proceed when it is safe to do so. I shall vacate area on
request or alarm. I shall not interfere with on-line equipment.
Name Sign Dept/Partner Date Time Completed
/ / : Yes/No
/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

/ / : Yes/No

(All must attach locks/personal danger tags at each isolation point.)

Responsible Person/s handing over equipment:

I or my work party has completed our work. All tools, materials and equipment from the
immediate vicinity of the work area have been removed, all flange guards replaced, all
Personal Danger tags and/or locks removed and the area cleaned.
Name Sign Dept/Partner Date Time Completed
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No
/ / : Yes / No

Page 4 of 4 M3-FST-FOR-HSE00-GEN-000037