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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.
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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.
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.
Full Name and Signature of Person Engaging Contractor/Worker
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.
Full Name and Signature of Permit to Work Authorized Person
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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