close
lumiform
LumiformMobile audits & inspections
Get AppGet App

Permit to Work Template

This permit to work template was divided into 3 sections: Permit request, person engaging contractor or worker review and authorization. Each section entails confirmation from the persons-in-charge in accordance with key processes and protocols to ensure a safe working environment. Use Lumiform to create checklists with mandatory signature fields to validate audits and inspections. all specified high-risk tasks invoked with a work activity.
Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on lumiformapp.com and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra
App StorePlay Store

Permit to Work Template

Permit Request

Work Activity Title

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

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.

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

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

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

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.

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

I am requesting this Permit to be reviewed, registered and numbered by the Permit to Work Authorised Person.

Completion

Full Name and Signature of Supervisor

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.

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.

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.

Completion

Full Name and Signature of Person Engaging Contractor/Worker

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.

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

Complete

Full Name and Signature of Permit to Work Authorized Person

Share this template: