30/05/2024 11:34 Permit to Work Template - SafetyCulture

Go digital today!
Convert your paper checklists into digital forms
Scan this QR code to use this paper checklist on your smartphone or
tablet or visit https://safetyculture.com/

Title Page

Company/Entity doing the work

Location/Work Site 

Conducted on 

Prepared by

Permit Request

Work Activity Title

Specified high-risk work tasks covered to work by this permit

Plant Work Live Electrical

Hot Confined Excavation Isolation at Maintenance Other
Work Space Heights Work

https://public-library.safetyculture.io/products/permit-to-work-template?amp_dev=bd6dea40-bac2-4d19-aacc-aadc8704aa02&sID=1713194814238 1/5
30/05/2024 11:34 Permit to Work Template - SafetyCulture

Start of Work 

End of Work 

Permit Request (On-site supervisor of the contractor/workers who have been

engaged to perform the work)

This acknowledgement signifies a formal request to commence a work activity invoking

one or more specified high-risk tasks. As the person requesting this permit, I hereby
certify that

I have developed and/or reviewed the Risk Assessment and required Control Form/s
relevant to this work activity.

Yes No N/A

I have consulted with relevant people to ensure that controls are adequate.

Yes No N/A

I am competent to coordinate this work activity in accordance with the attached Risk
Assessment and Control Form/s.

Yes No N/A

I shall undertake to implement all planned and necessary controls to ensure the health
and safety of those completing or impacted by the activity.

Yes No N/A

I shall ensure that the persons required to carry out the work are advised of and
understand the requirements of the Risk Assessment and Control Form/s, and the
Permit To Work / Access Instructions in Section 4 below.

Yes No N/A

https://public-library.safetyculture.io/products/permit-to-work-template?amp_dev=bd6dea40-bac2-4d19-aacc-aadc8704aa02&sID=1713194814238 2/5
30/05/2024 11:34 Permit to Work Template - SafetyCulture

I shall monitor hazards and control methods throughout the work activity.

Yes No N/A

I am requesting this Permit to be reviewed, registered and numbered by the Permit to

Work Authorised Person.

Yes No N/A

Completion

Full Name and Signature of Supervisor 

https://public-library.safetyculture.io/products/permit-to-work-template?amp_dev=bd6dea40-bac2-4d19-aacc-aadc8704aa02&sID=1713194814238 3/5
30/05/2024 11:34 Permit to Work Template - SafetyCulture

Person Engaging Contractor/Worker Review

Person Engaging Contractor/Worker Review

This sign off is to signify that the PBPL person who engaged the contractor/worker has
reviewed all documentation and provided comments

I have reviewed the content of all related documents including the Risk Assessment and
required Control Form/s and provided feedback to the contractor/workers.

Yes No N/A

I confirm as the person who engaged the contractor/worker, I will monitor the methods
of work and the implementation of the proposed controls to ensure that standards for
health and safety are being achieved throughout the works.

Yes No N/A

I have informed the relevant person/s for the area that the work is being performed in,
the full scope of works to be completed by the contractor/workers and the processes
developed for supervising and enforcing the works.

Yes No N/A

Completion

Full Name and Signature of Person Engaging


Contractor/Worker

https://public-library.safetyculture.io/products/permit-to-work-template?amp_dev=bd6dea40-bac2-4d19-aacc-aadc8704aa02&sID=1713194814238 4/5
30/05/2024 11:34 Permit to Work Template - SafetyCulture

Authorization

Authorization

This authorization signifes that the planning component of the work activity has been
completed and that the work is authorized to commence in accordance with the risk
assessment and required control forms. As the Permit to Work Authorized , i hereby
certify:

I have reviewed the content of all related documents including the Risk Assessment and
required Control Form/s.

Yes No N/A

I have registered this permit in the Permit To Work Register, allocated it a number and
have written the number on all associated documents.

Yes No N/A

Complete

Full Name and Signature of Permit to Work


Authorized Person

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's
solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should
independently determine whether the template is suitable for your circumstances.

https://public-library.safetyculture.io/products/permit-to-work-template?amp_dev=bd6dea40-bac2-4d19-aacc-aadc8704aa02&sID=1713194814238 5/5