SmartCheck | COMPUTERISED MAINTENANCE MANAGEMENT SYSTEM

Raise WorkPermit

Name of the Person Raising/Initiating permit^*

Permit No^*

Location of work^*

Start Date^*

Start Time^*

12 hours format

End Date^*

End Time^*

12 hours format

Work initiated by^*

Permit Issued To ^*

No.of Contract Employees going to work ^*

Contractor Supervisor Names & contact no ^*

Basic Safety guidelines for contractor

Safe working practices must be always observed

No Alcohol/smoking/Chewing of tobacco in the workplace

PM/EHS in charge/process owner to approve Equipment's/material/tools and tackles/chemicals

Approved quality PPE's to be used at site

Warning signages must be obeyed

All injuries to be reported to Site in charge

Safety is everybody's responsibility

Contractor Declaration

I have read and understood the safety guidelines of the company and will ensure/own responsibility for all the employees deployed at the time of execution of works by abiding to company safety guidelines. We ensure during above mentioned work period any damages or loss of property will be borne by us

Is Buddy system required

Buddy Name

Is LOTOTO system required

LOTOTO no

Applied by

Released by

WorkPermit Type^*

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Electrocution/electric hazard

Fire

Slip Trip Fall

Falling object

Vibration & Noise

Manual Handling

Chemical Handling

Control of hazards

Ladder

Ear Muffs

Fall arrester

Safety shoe

Goggles

Helmet

Tool kit bag

Full body harness

Barrication

Machine guarding

Nose mask

Standard tools

Lock out-Tag out

Adequate lighting

Buddy system

Additional support

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Fall from heights

Falling of materials from heights

Electrocution

Risk of Falling Persons

Unsecured Ladders

Uneven Floor Surfaces

Manual Handling of Loads

Control of hazards

Ladder

Safety shoe

Goggles

Helmet

Tool kit bag

Lifeline

Full body harness

Barrication

Machine guarding

Nose mask

Standard tools

Adequate lighting

Buddy system

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Inadequate lighting

Electric Shocks

Safety Systems bypassed or disabled

Damaged tools and equipment

Exposed electrical parts

Flammable or combustible materials

Damaged insulation

Control of hazards

Electrical Safety shoe

Electrical gloves

Fire extinguisher

Sand bucket

Barrication

Machine guarding

Nose mask

Standard tools

Lock out-Tag out

Electrical discharge rod

ELCB/RCB

Adequate lighting

Buddy system

Working platform

Tool box talk

Line Clearance for overhead power lines

Below To be completed and authorized by Shift In charge

Do work need to be carried out at live circuit or energized system? If Yes state reason ^*

Specific legal/statutory requirements (if any): (ex.:Class 1 Electrical contractor license) ^*


	SNO	Energy Type(Electrical, mechanical pressure, heat & chemical)	Isolation Point (Locking point, Blocking point or Linkage removal point)	Point to disconnect or dissipate any stored energy	Method/place to verify no residual energy exists

Lock Out Tag Out Try Out Checklist (If NO please explain) by FM/PM

Isolation (LOTOTO) performed by

Are locks used of approved type

Are tags properly placed and up-to-date

Lock out Tag out and Try out recorded in log book

Area is barricaded with signage

Electrically insulated tools are used

Isolation verification done by Shift engineer

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

Electric Shock

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Electrocution/electric hazard

Fire

Oxygen Depletion

Explosion

Open flames or arc will be generated

Flying Particles or sparks

Safety Systems bypassed or disabled

Burn hazard

Flammable or combustible materials

Toxic Fumes

Work adjacent to normal work area

Physical injury

Damage tools

CONTROL MEASURES FOR HAZARDS(Tick here for controls applied)

Face shield

Welding apron

Safety shoe

Leather gloves

Fire extinguisher

Sand bucket

Barrication

Machine guarding

Nose mask

Flash back arrester

Cylinder trolly

Standard tools

Lock out-Tag out

Fire watcher

Fire blanket

Adequate lighting

Adequate Ventilation

Buddy system

Additional support

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards/Control measures

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

To be completed : Permit issuer

Smoke/heat detectors to be disconnected/covered for duration of work

Area cleared of all combustible material and of flammable liquid or gases within 10 meter radius of the work

Flash back arrestors fitted to gas cylinders and torch

Fire Extinguisher availability at work location

Hot work area has adequate ventilation

Fire watch will be available throughout the work and 1 hour after completion of work

Gas cylinder secured in upright position

Workers have all appropriate PPE.

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Reduced Oxygen Levels

Risk of fire

Flooding/Drowning

Asphyxiation

Arc Flash

Danger of falling from heights

Flammable or combustible

Dangerous gases

Work adjacent to normal work area

Entrapment

Others

CONTROL MEASURES FOR HAZARDS (Tick here for controls applied)

Electrical Safety shoe

Gloves

Reflective Jacket

Fire extinguisher

Barrication

Machine guarding

Respiratory Mask

SCBA

Standard tools

Lock out-Tag out

Gas detectors

Mechanical Ventilation

Adequate lighting

Person with Lifeline

Working platform

Tripod with Retracting System

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards/Control measures

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

To be completed by FM/PM

Confined Space Area/location

Confined Space No

Equipment used

Entry Supervisor

Entrant

Person with lifeline

Completed By Confined Space Assessor


	SNO	Date / Time	Area/depth of the location	Sample By	Oxygen % (19 - 23%)	Toxic gases %(Methane, CO2, etc.)

Authorization

I verified that the requirements for working at height have been complied with. This Task Sheet is issued and remains valid under the conditions mentioned above.
Issuer Name:		Issuer Date:^*

Receiver Name:		Receiver Date:^*

EHS coordinator Name:		EHS coordinator Date:^*

FM/PM Name:		FM/PM Date:^*

EMERGENCY CONTACT NUMBER

Note: No extension of work permit beyond 6:00 PM. If requirement raises fresh work permit to be raised

Format No

Revision No

Date^*

Emergency Contact Number

Raise WorkPermit

Name of the Person Raising/Initiating permit^*

Permit No^*

Location of work^*

Start Date^*

Start Time^*

12 hours format

End Date^*

End Time^*

12 hours format

Work initiated by^*

Permit Issued To ^*

No.of Contract Employees going to work ^*

Contractor Supervisor Names & contact no ^*

Basic Safety guidelines for contractor

Safe working practices must be always observed

No Alcohol/smoking/Chewing of tobacco in the workplace

PM/EHS in charge/process owner to approve Equipment's/material/tools and tackles/chemicals

Approved quality PPE's to be used at site

Warning signages must be obeyed

All injuries to be reported to Site in charge

Safety is everybody's responsibility

Contractor Declaration

I have read and understood the safety guidelines of the company and will ensure/own responsibility for all the employees deployed at the time of execution of works by abiding to company safety guidelines. We ensure during above mentioned work period any damages or loss of property will be borne by us

Is Buddy system required

Buddy Name

Is LOTOTO system required

LOTOTO no

Applied by

Released by

WorkPermit Type^*

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Electrocution/electric hazard

Fire

Slip Trip Fall

Falling object

Vibration & Noise

Manual Handling

Chemical Handling

Control of hazards

Ladder

Ear Muffs

Fall arrester

Safety shoe

Goggles

Helmet

Tool kit bag

Full body harness

Barrication

Machine guarding

Nose mask

Standard tools

Lock out-Tag out

Adequate lighting

Buddy system

Additional support

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Fall from heights

Falling of materials from heights

Electrocution

Risk of Falling Persons

Unsecured Ladders

Uneven Floor Surfaces

Manual Handling of Loads

Control of hazards

Ladder

Safety shoe

Goggles

Helmet

Tool kit bag

Lifeline

Full body harness

Barrication

Machine guarding

Nose mask

Standard tools

Adequate lighting

Buddy system

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Inadequate lighting

Electric Shocks

Safety Systems bypassed or disabled

Damaged tools and equipment

Exposed electrical parts

Flammable or combustible materials

Damaged insulation

Control of hazards

Electrical Safety shoe

Electrical gloves

Fire extinguisher

Sand bucket

Barrication

Machine guarding

Nose mask

Standard tools

Lock out-Tag out

Electrical discharge rod

ELCB/RCB

Adequate lighting

Buddy system

Working platform

Tool box talk

Line Clearance for overhead power lines

Below To be completed and authorized by Shift In charge

Do work need to be carried out at live circuit or energized system? If Yes state reason ^*

Specific legal/statutory requirements (if any): (ex.:Class 1 Electrical contractor license) ^*


	SNO	Energy Type(Electrical, mechanical pressure, heat & chemical)	Isolation Point (Locking point, Blocking point or Linkage removal point)	Point to disconnect or dissipate any stored energy	Method/place to verify no residual energy exists

Lock Out Tag Out Try Out Checklist (If NO please explain) by FM/PM

Isolation (LOTOTO) performed by

Are locks used of approved type

Are tags properly placed and up-to-date

Lock out Tag out and Try out recorded in log book

Area is barricaded with signage

Electrically insulated tools are used

Isolation verification done by Shift engineer

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

Electric Shock

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Electrocution/electric hazard

Fire

Oxygen Depletion

Explosion

Open flames or arc will be generated

Flying Particles or sparks

Safety Systems bypassed or disabled

Burn hazard

Flammable or combustible materials

Toxic Fumes

Work adjacent to normal work area

Physical injury

Damage tools

CONTROL MEASURES FOR HAZARDS(Tick here for controls applied)

Face shield

Welding apron

Safety shoe

Leather gloves

Fire extinguisher

Sand bucket

Barrication

Machine guarding

Nose mask

Flash back arrester

Cylinder trolly

Standard tools

Lock out-Tag out

Fire watcher

Fire blanket

Adequate lighting

Adequate Ventilation

Buddy system

Additional support

Working platform

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards/Control measures

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

To be completed : Permit issuer

Smoke/heat detectors to be disconnected/covered for duration of work

Area cleared of all combustible material and of flammable liquid or gases within 10 meter radius of the work

Flash back arrestors fitted to gas cylinders and torch

Fire Extinguisher availability at work location

Hot work area has adequate ventilation

Fire watch will be available throughout the work and 1 hour after completion of work

Gas cylinder secured in upright position

Workers have all appropriate PPE.

HAZARD IDENTIFICATION FOR WORK UNDERTAKEN (To be completed for all work)

Reduced Oxygen Levels

Risk of fire

Flooding/Drowning

Asphyxiation

Arc Flash

Danger of falling from heights

Flammable or combustible

Dangerous gases

Work adjacent to normal work area

Entrapment

Others

CONTROL MEASURES FOR HAZARDS (Tick here for controls applied)

Electrical Safety shoe

Gloves

Reflective Jacket

Fire extinguisher

Barrication

Machine guarding

Respiratory Mask

SCBA

Standard tools

Lock out-Tag out

Gas detectors

Mechanical Ventilation

Adequate lighting

Person with Lifeline

Working platform

Tripod with Retracting System

Tool box talk

WORKER BRIEFING

All members of the work party have been briefed on

Potential Hazards/Control measures

Safe Work procedures

Description of the Permit

Evacuation process

Incidents reporting process

Emergency Contact

Medical Health Centre

To be completed by FM/PM

Confined Space Area/location

Confined Space No

Equipment used

Entry Supervisor

Entrant

Person with lifeline

Completed By Confined Space Assessor


	SNO	Date / Time	Area/depth of the location	Sample By	Oxygen % (19 - 23%)	Toxic gases %(Methane, CO2, etc.)

Authorization

I verified that the requirements for working at height have been complied with. This Task Sheet is issued and remains valid under the conditions mentioned above.
Issuer Name:		Issuer Date:^*

Receiver Name:		Receiver Date:^*

EHS coordinator Name:		EHS coordinator Date:^*

FM/PM Name:		FM/PM Date:^*

EMERGENCY CONTACT NUMBER

Note: No extension of work permit beyond 6:00 PM. If requirement raises fresh work permit to be raised

Format No

Revision No

Date^*

Emergency Contact Number

Cancel WorkPermit

I have inspected the work and hereby cancel this work permit for the following reason

Emergency called at site

Safety guidelines not followed

LOTO guideline not followed

Work permit guidelines not followed

Name:

Close WorkPermit

I have inspected the work and hereby close this work permit

Work completed as per the safety guidelines and all the systems restored

The work area is cleaned and secured

LOTOTO system is removed

All the system repositioned to normal operating mode

All hazardous material properly disposed

Smoke detector cap uncovered

Is DG shifted to Auto mode

System is made normal on FAS panel and all knob are on pipeline are on ON condition

Hydrant and sprinkler system is pressurized

Name:

	Company Name

	Name
	Email Id
	User ID / Mobile Number
	Address

	Location
	Pin Code