Site Safety & Administration
Permit to Work
Formal authorisation for high-risk work activities including hot work, confined space entry, electrical isolation, and work at heights, per WHS Regulation.
33 checklist items
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Checklist Items
| Item | Pass / Yes | Fail / No |
|---|---|---|
| PERMIT INFORMATION | ||
| Permit Number | ___________________________ | |
| Site / Project Name | ___________________________ | |
| Date of Issue | ___________________________ | |
| Valid From (Time) | ___________________________ | |
| Valid Until (Time) | ___________________________ | |
| Work Location / Area | ___________________________ | |
| WORK TYPE | ||
| Hot Work (welding, grinding, cutting) | Yes ☐ | No ☐ |
| Confined Space Entry | Yes ☐ | No ☐ |
| Electrical Isolation / Live Work | Yes ☐ | No ☐ |
| Work at Heights (>2m) | Yes ☐ | No ☐ |
| Excavation / Trenching | Yes ☐ | No ☐ |
| Hazardous Substance Work | Yes ☐ | No ☐ |
| Other (describe) | ___________________________ | |
| WORK DESCRIPTION | ||
| Description of Work to be Performed | ___________________________ | |
| Equipment / Tools to be Used | ___________________________ | |
| Persons Performing the Work | ___________________________ | |
| PRE-WORK CHECKS | ||
| SWMS / JSA prepared and reviewed by workers | Yes ☐ | No ☐ |
| Hazardous area isolated (LOTO applied where required) | Pass ☐ | Fail ☐ |
| Atmosphere tested (for confined space / hot work) | Pass ☐ | Fail ☐ |
| Fire extinguisher / suppression equipment in place | Pass ☐ | Fail ☐ |
| PPE identified and available | Pass ☐ | Fail ☐ |
| Communication method agreed | Yes ☐ | No ☐ |
| Rescue plan in place (confined space / heights) | Yes ☐ | No ☐ |
| Adjacent workers / public notified | Yes ☐ | No ☐ |
| APPROVALS | ||
| Issuing Authority Name | ___________________________ | |
| Issuing Authority Signature | ___________________________ | |
| Permit Receiver / Worker-in-Charge Name | ___________________________ | |
| Permit Receiver Signature | ___________________________ | |
| PERMIT CLOSE-OUT | ||
| Work completed satisfactorily? | Yes ☐ | No ☐ |
| Area left safe and clean? | Yes ☐ | No ☐ |
| Isolations removed / services reinstated? | Yes ☐ | No ☐ |
| Permit Close-Out Date | ___________________________ | |
| Closing Authority Signature | ___________________________ | |