I have discussed the work method and relevant safety precautions to ensure work is being carried out safely

by my team. I have also

confirmed my worker is not showing any sign of fatigue and I ensure workers are not consuming alcohol or any drug.
Supervisor / P. Holder Name: ________________________ Signature: ________________ Date/Time: __________________
PTW Number:

My supervisor has explained very clearly, and I have agreed and admitted about the above statement.

Topic :

Signature
S/No Worker Name Designation Time Time Time
( ) ( ) ( )
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Witnessed by HSSE (Name): _______________________ Designation: _____________________Sign/Time________________

Endorsed by PTW Holder (Name): ________________________ Designation: _______________ Sign/Time ________________