Permit-to-work form

• Pages: 123-124

123

Appendix I Permit-to-work form1

Note: The responsible officer should indicate the sections applicable by marks in the left-

hand spaces next to the headings, and by deleting any subheading not applicable. The officer

should insert the appropriate details when the sections for Other work or Additional precautions

are used.

The person in charge of the work should mark each applicable right-hand space when

completing each check.

Work to be done ______________________________________________________________________

Period of validity of permit ______________________________________________________________

Location ____________________________________________________________________________

Person in charge of the work _____________________________________________________________

Persons performing the work ____________________________________________________________

Responsible officer (signature) __________________________________________________________

Date ______________________________________ Time _____________________________________

Master's signature _____________________________________________________________________

Date ______________________________________ Time _____________________________________

Entry into enclosed or confined spaces

____________ Space thoroughly ventilated ____________

____________ Atmosphere tested and found safe ____________

____________ Rescue and resuscitation equipment available at entrance ____________

____________ Responsible person in attendance at entrance ____________

____________ Communication arrangements made between person at entrance

and those entering ____________

____________ Access and illumination adequate ____________

____________ All equipment to be used is of an approved type ____________

____________ When breathing apparatus is to be used:

(1) familiarity of user with apparatus is confirmed ____________

(2) apparatus has been tested and found to be satisfactory ____________

Machinery or equipment

____________ Removed from service/isolated from sources of power or heat ____________

____________ All relevant personnel informed ____________

____________ Warning notices displayed ____________

1 Based upon the form found in the Department of Transport's Code of safe working practices for

merchant seamen (London, HMSO, 1991).