SmartCheck | COMPUTERISED MAINTENANCE MANAGEMENT SYSTEM

Vendor Request Form

Select Department^*

Select Asset^(Optional)

Select Sub Asset^(Optional)

Document No^*

Requester Name^*

Requester Designation^*

Requester Contact No^*

Smart services Process Owner Name^*

Contact no^*

Site Co-Ordinator From Dept/ Contractor Name^*

Contact No^*

No. of workers expected to be placed at the site^*

Scheduled WorkDay

Proposed Start Date^*

Start Time^*

12 hours format

Mandatory HR Requirements: (Proof of following evidences to be shared with the Process Owner)

Workmen's Compensation for all staff to be deputed at Smart services

ESI for staff to be deputed at Smart services

Contractors personnel medical certificates and reports to perform particular task

WC, ESI, PF, medical reports and Gov. ID evidence

Are children below 14 years engaged in the work?

Inspected the work site with concerned team and understood the work to be done

Brief Description of Work^*

List of all workers

Safe Operating Procedure

All the PPE & equipment, tools and tackles using at the site has a valid test reports and certificates

Hot Work

Confined Space entry

Utility Vaults	Tanks	Water Supply Towers
Sewers, Pipes	Access Shafts	Boilers
Man Holes	Pump Stations	STP Digesters
Manure Pits	Enclosed Storage	H2S / CO
Oxygen Deficiency	Others^*

Working at Height

Electrical/ Mechanical/ LOTO

Excavation

General

Potential impacts

Will the work involve or have the potential to impact

Will work involve climbing/standing on or working above equipment or utility systems?

Does the work involve a tool or equipment movement?

Do switches, buttons, pipes, gauges or valves need to be protected or supported?

Does the work require flushing, discharging or draining of fluids?

Will work involve interruption of or redirecting personnel traffic / travel paths?

Will work involve drilling, coring, or hammering into the facility?

Others^*

Personal Protective Equipment required (PPEs)

Hard Hat

Face Shield

Welder Gloves

Electrical Gloves

Body Harness

Foot Protection

Ear Plug / Earmuffs

Chemical Goggles

Surgical Gloves

Safety Shoes

Special Clothing

Respirator

Safety Glass

Barricading

Rubber Gloves

Rubber Shoes

Fall Protection

Others^*

Equipment / Tools required

Fire Extinguishers

Warning Signs

Walkie-talkie

Ladder / scaffold

Fire Hoses

Non- Sparking Tools

Mech. Ventilation

Gas Detector

Additional Lighting

Explosion Proof Eqpt

Eye Wash

Others^*

To be filled by the Safety Officer

JSA (Job Safety Analysis)

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Required permits and systems

Hot Work Permit
Confined Space Entry Permit
Working at Height Permit
Electrical / Mechanical Work / LOTO Permit
Excavation Permit
General Work Permit
Energy Isolation Work Permit
Instructions to Contractor

To be filled by Requestor (Dept/ Contractor)

I confirm that I fully understand the hazards and the precautions as specified in JSA and discussed during job site inspection. I hereby agree to the safety requirements and undertake to carry out the work accordingly and ensure the all precautions are followed. (Requestor should approach Process owner with all the required details after review with Safety officer and ensure all the instructions are followed as mentioned)
Name:		Date:^*

To be filled by the Process Owner (Permit Issuer)

I have reviewed the documentation with evidences. Visited the site and discussed the job-related risks and control measures with the Dept/Contractor and permit will be granted subject to conditions stated herein. I am the authorized signatory.
Instructions to Contractor
Name:		Date:^*

General Instructions to Contractors
1. All the employees entering the premises shall be given an Identity card of the company which will be countersigned by the security Head of the premises. Entry will be denied to personnel without this identification. 2. A Safety Training will be conducted at every site at 9:30 am by the Safety representative in the training room on a daily basis. 3. Each team member who successfully undergoes the session will be provided a sticker confirming completion of the induction process valid for a pre stipulated time duration. This sticker will be stuck on his ID card that needs to be displayed prominently while at the site. 4. Transitional storage of materials at the common areas is also prohibited. 5. Occupant / Tenant / lessee are requested to keep any rough and wet work within their demised areas to the minimum and to avoid any operations that create excessive dust and produce hazardous conditions. 6. All hacking, drilling, demolition, and noisy works are to be carried out after office hours (i.e. after 6.00 pm on). In the case where the noisy works will affect the other office`s operation, the business hours of the said office will have to be observed. Occupant / Tenant / lessee is required to inform Responsible officer in advance prior to the commencement of such works for necessary coordination with other occupants. 7. In order to maintain a high standard of hygiene, cleanliness and safety at the site, please ensure that the contractor clear the debris from the workplace immediately after completion of day`s work. 8. Mixing the cement in the toilets is prohibited. Leftover cement mortar/slurry shall not be disposed off into water closets, basins or floor traps. The areas under renovation have to be maintained clean and free from all pests at all times. 9. Only the service lift is permitted to convey renovation materials, tools, and debris. Passenger lifts are not to be used for this purpose. 10. Approval has to be sought before commencement of any works at the common areas. 11. All finishes and installations in common areas, such as doors, lifts and wallpapers are to be well protected to prevent damage during the work period, if permitted for using the common area. 12. Workers are to be confined within the demised premises. They are not to loiter during their break times. 13. Smoking is strictly prohibited inside the premises. 14. No obstruction to fire escape routes, hose reels, and other firefighting provisions is allowed in the course of your works 15. Electricity drawn from the power points shall be via properly fused electrical plugs. Drawing power supply by placing of exposed wiring terminals into the plug sockets is not allowed under any circumstances. 16. No puncturing of any component of the aluminium window frame shall be permitted to facilitate fixing dry wall partitions 17. Please note that, in the event your contractors'/sub-contractors' workers create a nuisance or persistently ignore the instructions, they will not be permitted access to the site. 18. Utmost care to be taken while working close to the charged sprinkler at the ceiling. Any damage to the same shall be charged to the concerned contractor. 19. Illegal activities are not permitted inside the building. Any individual caught in the act shall be taken into the serious course of action. 20. The contractor shall follow all safety precautions and shall be liable for any injuries / losses / damages to personnel and property.

Vendor Request Form

Select Department^*

Select Asset^(Optional)

Select Sub Asset^(Optional)

Permit No^*

Document No^*

Requester Name^*

Requester Designation^*

Requester Contact No^*

Smart services Process Owner Name^*

Contact no^*

Site Co-Ordinator From Dept/ Contractor Name^*

Contact No^*

No. of workers expected to be placed at the site^*

Scheduled WorkDay

Proposed Start Date^*

Start Time^*

12 hours format

Mandatory HR Requirements: (Proof of following evidences to be shared with the Process Owner)

Workmen's Compensation for all staff to be deputed at Smart services

ESI for staff to be deputed at Smart services

Contractors personnel medical certificates and reports to perform particular task

WC, ESI, PF, medical reports and Gov. ID evidence

Are children below 14 years engaged in the work?

Inspected the work site with concerned team and understood the work to be done

Brief Description of Work^*

List of all workers

Safe Operating Procedure

All the PPE & equipment, tools and tackles using at the site has a valid test reports and certificates

Hot Work

Confined Space entry

Utility Vaults	Tanks	Water Supply Towers
Sewers, Pipes	Access Shafts	Boilers
Man Holes	Pump Stations	STP Digesters
Manure Pits	Enclosed Storage	H2S / CO
Oxygen Deficiency	Others^*

Working at Height

Electrical/ Mechanical/ LOTO

Excavation

General

Potential impacts

Will the work involve or have the potential to impact

Will work involve climbing/standing on or working above equipment or utility systems?

Does the work involve a tool or equipment movement?

Do switches, buttons, pipes, gauges or valves need to be protected or supported?

Does the work require flushing, discharging or draining of fluids?

Will work involve interruption of or redirecting personnel traffic / travel paths?

Will work involve drilling, coring, or hammering into the facility?

Others^*

Personal Protective Equipment required (PPEs)

Hard Hat

Face Shield

Welder Gloves

Electrical Gloves

Body Harness

Foot Protection

Ear Plug / Earmuffs

Chemical Goggles

Surgical Gloves

Safety Shoes

Special Clothing

Respirator

Safety Glass

Barricading

Rubber Gloves

Rubber Shoes

Fall Protection

Others^*

Equipment / Tools required

Fire Extinguishers

Warning Signs

Walkie-talkie

Ladder / scaffold

Fire Hoses

Non- Sparking Tools

Mech. Ventilation

Gas Detector

Additional Lighting

Explosion Proof Eqpt

Eye Wash

Others^*

To be filled by the Safety Officer

JSA (Job Safety Analysis)

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Required permits and systems

Hot Work Permit
Confined Space Entry Permit
Working at Height Permit
Electrical / Mechanical Work / LOTO Permit
Excavation Permit
General Work Permit
Energy Isolation Work Permit
Instructions to Contractor

To be filled by Requestor (Dept/ Contractor)

I confirm that I fully understand the hazards and the precautions as specified in JSA and discussed during job site inspection. I hereby agree to the safety requirements and undertake to carry out the work accordingly and ensure the all precautions are followed. (Requestor should approach Process owner with all the required details after review with Safety officer and ensure all the instructions are followed as mentioned)
Name:		Date:^*

To be filled by the Process Owner (Permit Issuer)

I have reviewed the documentation with evidences. Visited the site and discussed the job-related risks and control measures with the Dept/Contractor and permit will be granted subject to conditions stated herein. I am the authorized signatory.
Instructions to Contractor
Name:		Date:^*

General Instructions to Contractors
1. All the employees entering the premises shall be given an Identity card of the company which will be countersigned by the security Head of the premises. Entry will be denied to personnel without this identification. 2. A Safety Training will be conducted at every site at 9:30 am by the Safety representative in the training room on a daily basis. 3. Each team member who successfully undergoes the session will be provided a sticker confirming completion of the induction process valid for a pre stipulated time duration. This sticker will be stuck on his ID card that needs to be displayed prominently while at the site. 4. Transitional storage of materials at the common areas is also prohibited. 5. Occupant / Tenant / lessee are requested to keep any rough and wet work within their demised areas to the minimum and to avoid any operations that create excessive dust and produce hazardous conditions. 6. All hacking, drilling, demolition, and noisy works are to be carried out after office hours (i.e. after 6.00 pm on). In the case where the noisy works will affect the other office`s operation, the business hours of the said office will have to be observed. Occupant / Tenant / lessee is required to inform Responsible officer in advance prior to the commencement of such works for necessary coordination with other occupants. 7. In order to maintain a high standard of hygiene, cleanliness and safety at the site, please ensure that the contractor clear the debris from the workplace immediately after completion of day`s work. 8. Mixing the cement in the toilets is prohibited. Leftover cement mortar/slurry shall not be disposed off into water closets, basins or floor traps. The areas under renovation have to be maintained clean and free from all pests at all times. 9. Only the service lift is permitted to convey renovation materials, tools, and debris. Passenger lifts are not to be used for this purpose. 10. Approval has to be sought before commencement of any works at the common areas. 11. All finishes and installations in common areas, such as doors, lifts and wallpapers are to be well protected to prevent damage during the work period, if permitted for using the common area. 12. Workers are to be confined within the demised premises. They are not to loiter during their break times. 13. Smoking is strictly prohibited inside the premises. 14. No obstruction to fire escape routes, hose reels, and other firefighting provisions is allowed in the course of your works 15. Electricity drawn from the power points shall be via properly fused electrical plugs. Drawing power supply by placing of exposed wiring terminals into the plug sockets is not allowed under any circumstances. 16. No puncturing of any component of the aluminium window frame shall be permitted to facilitate fixing dry wall partitions 17. Please note that, in the event your contractors'/sub-contractors' workers create a nuisance or persistently ignore the instructions, they will not be permitted access to the site. 18. Utmost care to be taken while working close to the charged sprinkler at the ceiling. Any damage to the same shall be charged to the concerned contractor. 19. Illegal activities are not permitted inside the building. Any individual caught in the act shall be taken into the serious course of action. 20. The contractor shall follow all safety precautions and shall be liable for any injuries / losses / damages to personnel and property.

Extended WorkPermit

Extended Period^*

Reason

Remarks

General Workpermit

1. If conditions change, cease work immediately, notify the FM team, and the permit will be automatically invalidated
2. This permit is valid for one day only. For work required on subsequent days, a new work permit must be applied for.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Brief description of the work^*


	SNO	Job Performers Name /Mobile No

To be filled by HSE

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Permit Originator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

General Workpermit

1. If conditions change, cease work immediately, notify the FM team, and the permit will be automatically invalidated
2. This permit is valid for one day only. For work required on subsequent days, a new work permit must be applied for.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Brief description of the work^*


	SNO	Job Performers Name /Mobile No

To be filled by HSE

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Permit Originator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

General Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Brief description of the work^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

JSA (Job Safety Analysis)

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

General Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Brief description of the work^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

JSA (Job Safety Analysis)

	SNO	Task (steps to carry out the activity)	Hazard	Potential Risk	Existing control	Probability of occurrence	Severity	Risk Level	Additional control, if required	Action responsibility (Smart services/ contactor)

Probability of occurrence Severity	Rare -1	Occasional - 2	Frequent - 3
Major - 3
Moderate - 2
Minor - 1

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Hot Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Details of hot work to be done^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

HOT Work Checklist : Please mention N/A if not applicable
Person doing hot work has been trained in safe operation of equipment, and how to work safely
Smoke/heat detectors to be disconnected/covered forduration of work
Area cleared of combustible material
Area clear of flammable liquids or gases
Wooden flooring covered with sand or offer non- combustible material (steel plate etc.)
Turn off fixed gas supply or protect piping Flash back arrestors lifted to gas cylinders
Fire Extinguisher and fire blanket availability at site
Hot work area has adequate ventilation
Welders have all required PPE (eye protection, helmet, protective clothing, respirator, gloves, face shield, Safety shoe etc.)
Fire watchman will be available throughout the work
Welders are trained and certified as required by local law
Equipment/ tools to be used is in good condition
LPG, Acetylene, Oxygen cylinders kept separately and safely
Gas cylinder secured in upright position
Flash arrester provided for gas cutting equipment
No flammable material within 11-meter distance of the work, Notify affected personnel
Workers are briefed on emergency procedures
Other precautions (specify)
Mention the country specific legal/statutory requirement (if any)
Climatic conditions during work
Others(specify)
Fire Watch Name:	Start Time	End Time

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Hot Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Details of hot work to be done^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

HOT Work Checklist : Please mention N/A if not applicable
Person doing hot work has been trained in safe operation of equipment, and how to work safely
Smoke/heat detectors to be disconnected/covered forduration of work
Area cleared of combustible material
Area clear of flammable liquids or gases
Wooden flooring covered with sand or offer non- combustible material (steel plate etc.)
Turn off fixed gas supply or protect piping Flash back arrestors lifted to gas cylinders
Fire Extinguisher and fire blanket availability at site
Hot work area has adequate ventilation
Welders have all required PPE (eye protection, helmet, protective clothing, respirator, gloves, face shield, Safety shoe etc.)
Fire watchman will be available throughout the work
Welders are trained and certified as required by local law
Equipment/ tools to be used is in good condition
LPG, Acetylene, Oxygen cylinders kept separately and safely
Gas cylinder secured in upright position
Flash arrester provided for gas cutting equipment
No flammable material within 11-meter distance of the work, Notify affected personnel
Workers are briefed on emergency procedures
Other precautions (specify)
Mention the country specific legal/statutory requirement (if any)
Climatic conditions during work
Others(specify)
Fire Watch Name:	Start Time	End Time

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Confined Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Oxygen deficiency

Toxic gasses

Engulfment or Entrapment

Electrical Hazards

Flammable hazards (Gases, vapours, high oxygen)

Heat or Cold

Hazardous Configuration

Rotating or moving equipment

Chemical hazards

Others(specify)^*

Required Equipment

Respirator

Coveralls

Hearing protection

Explosive proof lighting

Fire Extinguisher

Harnesses

Emergency escape equipment

Resuscitator - Inhalator

Emergency Escape Respirator

Others(specify)^*

Entry Preparations

Ensure adequate (24 hrs) ventilation using portable air blower

Isolate hazardous energy

Apply locks and tags

Verify isolation

Secure area with barricading

Clean, drain and purge space

Shutoff all valves connecting to the space

Review hazard and work procedure

Notify available emergency team

Atmospheric test satisfactory

Additional permits obtained

Required PPE worn

Communication equipment availability

Worker are briefed on emergency situation procedure

Climatic condition during work

Others(specify)^*

Entry Supervisor^*

Attendant^*

Authorized Entrants^*

Emergency responder Name^*

Contact No^*

DO NOT ENTER IF LEVELS ARE NOT WITHIN PERMISSABLE LIMITS


	SNO	Date	Time	Sample by	Oxygen % (19.5%-21.5%)	Combustibles, % LEL (<5)	CO (<5 ppm)	H2S (<5 ppm)	Others, Specify	Remarks

Air Monitoring Equipment Used

Model^*

Serial No^*

Calibrated Date^*

Confined Space Assessor Name^*

Date^*

Time^*

12 hours format

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Confined Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Oxygen deficiency

Toxic gasses

Engulfment or Entrapment

Electrical Hazards

Flammable hazards (Gases, vapours, high oxygen)

Heat or Cold

Hazardous Configuration

Rotating or moving equipment

Chemical hazards

Others(specify)^*

Required Equipment

Respirator

Coveralls

Hearing protection

Explosive proof lighting

Fire Extinguisher

Harnesses

Emergency escape equipment

Resuscitator - Inhalator

Emergency Escape Respirator

Others(specify)^*

Entry Preparations

Ensure adequate (24 hrs) ventilation using portable air blower

Isolate hazardous energy

Apply locks and tags

Verify isolation

Secure area with barricading

Clean, drain and purge space

Shutoff all valves connecting to the space

Review hazard and work procedure

Notify available emergency team

Atmospheric test satisfactory

Additional permits obtained

Required PPE worn

Communication equipment availability

Worker are briefed on emergency situation procedure

Climatic condition during work

Others(specify)^*

Entry Supervisor^*

Attendant^*

Authorized Entrants^*

Emergency responder Name^*

Contact No^*

DO NOT ENTER IF LEVELS ARE NOT WITHIN PERMISSABLE LIMITS


	SNO	Date	Time	Sample by	Oxygen % (19.5%-21.5%)	Combustibles, % LEL (<5)	CO (<5 ppm)	H2S (<5 ppm)	Others, Specify	Remarks

Air Monitoring Equipment Used

Model^*

Serial No^*

Calibrated Date^*

Confined Space Assessor Name^*

Date^*

Time^*

12 hours format

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Height Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Falling Objects

Risk of falling beneath the platform

High Winds

Overhead Electric Cables

Unguarded Edges

Unsecured Ladders

Lack of Space

Uneven Floor Surfaces

Manual Handling of Loads

Others(specify)^*

What equipment will be used for Working at Height

Ladder (A Ladder/ Vertical/ Telescopic)

Scaffold (on site constructed)

Lifts (scissor lift/Boom lift/Vertical personnel Platform)

Mobile platform (mobile scaffold)

Suspended Scaffold

Others(specify)^*

Mention, certificates/ legal requirements (If any)^*

Working at Height Check list

I Confirm That
People assigned to work at height have been trained and are competent to do so
Person are medically fit to do work at height
All energy sources have been isolated and locked out
The surface is not too steep or slippery or fragile
Complete rope access kit available
All required PPEs are available and are in good condition
Workers are briefed on emergency situation procedures
Climatic conditions during work
Power Lines
Area must be clear of power lines by 4m or power lines must be de-energized
Ladders
In good working condition without any defects
Secured against movement at head & base
Any equipment to be carried to the task is secured to a belt or hoisted up separately
Any ladder work to be conducted in a pedestrian or vehicular area is cordoned off by barriers and signed
Step ladder spreaders locked into position
Ladder extends 1 meter above top rest position
Worker must use fall protection system and anchor to safe and sound point above head
Edge Protection
Handrails/ Guardrails/temporary rails are installed
Mechanical Aid Equipment: (scissor lift/Boom lift/Vertical personnel Platform/ Gondola)
Only Authorized person operate the equipment
Equipment providing mechanical elevation must be Safety approved with suitable height railings
The area for use is not impeded or in proximity to electrical cabling or live overhead wires
Fall arresting harness used for work
Area is properly barricaded with signage
Scaffolding / Mobile Platform
Scaffolding complies with applicable local legislation
Scaffolding equipment with toe-boards & guardrails
Mobile platform wheels locked when in use
Mobile scaffolds must not be moved when occupied
Outriggers are in place for stability
Falling Objects
Mesh barriers have been installed to prevent objects being dislodged from height
All replacement parts and replaced parts will be secured at height
Secured buckets or other suitable containers are to be used for bolts/small parts

Rope Details


	Sl.No	Rope	Model	Serial No	Calibrated Date

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Height Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Falling Objects

Risk of falling beneath the platform

High Winds

Overhead Electric Cables

Unguarded Edges

Unsecured Ladders

Lack of Space

Uneven Floor Surfaces

Manual Handling of Loads

Others(specify)^*

What equipment will be used for Working at Height

Ladder (A Ladder/ Vertical/ Telescopic)

Scaffold (on site constructed)

Lifts (scissor lift/Boom lift/Vertical personnel Platform)

Mobile platform (mobile scaffold)

Suspended Scaffold

Others(specify)^*

Mention, certificates/ legal requirements (If any)^*

Working at Height Check list

I Confirm That
People assigned to work at height have been trained and are competent to do so
Person are medically fit to do work at height
All energy sources have been isolated and locked out
The surface is not too steep or slippery or fragile
Complete rope access kit available
All required PPEs are available and are in good condition
Workers are briefed on emergency situation procedures
Climatic conditions during work
Power Lines
Area must be clear of power lines by 4m or power lines must be de-energized
Ladders
In good working condition without any defects
Secured against movement at head & base
Any equipment to be carried to the task is secured to a belt or hoisted up separately
Any ladder work to be conducted in a pedestrian or vehicular area is cordoned off by barriers and signed
Step ladder spreaders locked into position
Ladder extends 1 meter above top rest position
Worker must use fall protection system and anchor to safe and sound point above head
Edge Protection
Handrails/ Guardrails/temporary rails are installed
Mechanical Aid Equipment: (scissor lift/Boom lift/Vertical personnel Platform/ Gondola)
Only Authorized person operate the equipment
Equipment providing mechanical elevation must be Safety approved with suitable height railings
The area for use is not impeded or in proximity to electrical cabling or live overhead wires
Fall arresting harness used for work
Area is properly barricaded with signage
Scaffolding / Mobile Platform
Scaffolding complies with applicable local legislation
Scaffolding equipment with toe-boards & guardrails
Mobile platform wheels locked when in use
Mobile scaffolds must not be moved when occupied
Outriggers are in place for stability
Falling Objects
Mesh barriers have been installed to prevent objects being dislodged from height
All replacement parts and replaced parts will be secured at height
Secured buckets or other suitable containers are to be used for bolts/small parts

Rope Details


	Sl.No	Rope	Model	Serial No	Calibrated Date

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Excavation Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Electrocution

Explosion

Gas escape

Ingress of water causing flooding

Cave-ins

Falls into trenches or excavations

Tripping over equipment, debris and spoil

Excavated material or other objects falling on workers

Unstable adjacent structures

Mishandled or poorly placed materials

Hazardous atmosphere (noxious gases/lack of oxygen)

Incidents involving vehicles and other mobile equipment

Others(specify)^*

General Trenching and Excavation Rules

Inspection of the excavation/trench, including adjacent areas and protective systems, are conducted daily by a Competent Person

Keep heavy equipment away from trench edges

Keep surcharge loads at least 2 feet (0.6 meters) from trench edges

Know where underground utilities are located

Test for low oxygen, hazardous fumes and toxic gases

Inspect trenches at the start of each shift

Inspect trenches following a rainstorm

Do not work under raised loads

Excavation Checklist

Exact locations of underground installations and utilities available before excavation

Underground installations protected, supported, or removed as necessary to safeguard employees

The area surrounding the excavation/trench has been properly protected and barricaded

The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored

Hazardous surface encumbrances removed or supported

Excavated materials should be placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench

Protection from hazards associated with water accumulation assessed

Possible cave-in, failure of protective system, hazardous atmosphere or other hazardous conditions assessed before starting the work

A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) for each person in the excavation/trench

Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench

Employees exposed to public traffic provided with reflectorized or high-visibility safety vests

Employees instructed not to stand underneath loads

Employees protected from cave-ins by an adequate protective system except when excavations are

Hard hats and required PPE`s worn by all employees

If the excavation/trench is classified as a confined space, ensure monitoring (as required on the confined space entry permit) is performed before employees are allowed to enter

Climatic conditions during work

Workers are briefed on emergency procedures

LOTO applicable

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Excavation Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

Purpose^*


	SNO	Name of the Job Performers

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Which of the following hazards are associated?

Electrocution

Explosion

Gas escape

Ingress of water causing flooding

Cave-ins

Falls into trenches or excavations

Tripping over equipment, debris and spoil

Excavated material or other objects falling on workers

Unstable adjacent structures

Mishandled or poorly placed materials

Hazardous atmosphere (noxious gases/lack of oxygen)

Incidents involving vehicles and other mobile equipment

Others(specify)^*

General Trenching and Excavation Rules

Inspection of the excavation/trench, including adjacent areas and protective systems, are conducted daily by a Competent Person

Keep heavy equipment away from trench edges

Keep surcharge loads at least 2 feet (0.6 meters) from trench edges

Know where underground utilities are located

Test for low oxygen, hazardous fumes and toxic gases

Inspect trenches at the start of each shift

Inspect trenches following a rainstorm

Do not work under raised loads

Excavation Checklist

Exact locations of underground installations and utilities available before excavation

Underground installations protected, supported, or removed as necessary to safeguard employees

The area surrounding the excavation/trench has been properly protected and barricaded

The excavation (if 5 feet [1.5 meters] or deeper) is properly sloped or shored

Hazardous surface encumbrances removed or supported

Excavated materials should be placed at least 2 feet (0.6 meter) away from the edge of the excavation/trench

Protection from hazards associated with water accumulation assessed

Possible cave-in, failure of protective system, hazardous atmosphere or other hazardous conditions assessed before starting the work

A means of egress (such as a stairway, ladder, or ramp) is provided within 25 feet (7.6 meters) for each person in the excavation/trench

Walkways or bridges with standard handrails are provided where personnel are required to cross the excavation/trench

Employees exposed to public traffic provided with reflectorized or high-visibility safety vests

Employees instructed not to stand underneath loads

Employees protected from cave-ins by an adequate protective system except when excavations are

Hard hats and required PPE`s worn by all employees

If the excavation/trench is classified as a confined space, ensure monitoring (as required on the confined space entry permit) is performed before employees are allowed to enter

Climatic conditions during work

Workers are briefed on emergency procedures

LOTO applicable

Permit Initiator

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with hot work and I comply with all RMZ safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Electrical Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

No. of People working^*

Wireman`s licence available for all

Details of electrical/mechanical work to be done^*

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

Mention statutory requirements (If any)^*

Lock Out Tag Out


	SNO	Energy Type (Electrical, Mechanical Pressure, Heat & chemical)	Isolation Point ( locking point, Blocking point or Linkage removal)	Point to disconnected or dissipate any stored energy	Method / place to verify no residual energy exists

LOTO Checklist

Isolation (LOTO) performed by worker itself

Earthing & Discharge provided

Are locks used of approved type

Are tags properly placed and written

LOTO recorded in logbook

Isolation verification done by competent person

Electrical / Mechanical Work Checklist

Authorised / Certified person carryout the work

Electrical/ plumbing /sewer drawing or plan available

Area is barricaded with signage

Electrically insulated tools are used

Fuses removed

Cables disconnect

Main supply isolated

Climatic conditions during work

Workers are briefed on emergency procedures

If `NO` from above points please explain^*

Permit Receiver: Department/ Contractor

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with electrical or mechanical work and I comply with all Smart services safety guidelines.
Name:		Date:^*		Contact:

Electrical Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

No. of People working^*

Wireman`s licence available for all

Details of electrical/mechanical work to be done^*

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

Mention statutory requirements (If any)^*

Lock Out Tag Out


	SNO	Energy Type (Electrical, Mechanical Pressure, Heat & chemical)	Isolation Point ( locking point, Blocking point or Linkage removal)	Point to disconnected or dissipate any stored energy	Method / place to verify no residual energy exists

LOTO Checklist

Isolation (LOTO) performed by worker itself

Earthing & Discharge provided

Are locks used of approved type

Are tags properly placed and written

LOTO recorded in logbook

Isolation verification done by competent person

Electrical / Mechanical Work Checklist

Authorised / Certified person carryout the work

Electrical/ plumbing /sewer drawing or plan available

Area is barricaded with signage

Electrically insulated tools are used

Fuses removed

Cables disconnect

Main supply isolated

Climatic conditions during work

Workers are briefed on emergency procedures

If `NO` from above points please explain^*

Permit Receiver: Department/ Contractor

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with electrical or mechanical work and I comply with all Smart services safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

Energy Isolation Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

No. of People working^*

Wireman`s licence available for all

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Details of electrical/mechanical work to be done^*

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

Mention statutory requirements (If any): ^*

Lock Out Tag Out


	SNO	Energy Type- Electrical or Mechanical	Isolation Point and locks applied	Name of lock applicants	Authorized Signatories

LOTO Checklist

Isolation (LOTO) performed by authorized personnel

Earthing & Discharge provided

Locks used

Are tags properly placed and written

LOTO recorded in logbook

Electrical/Mechanical Work Checklist

Authorised person carryout the work

Electrical/ plumbing /sewer drawing or plan available

Area is barricaded with signage

Electrically insulated tools are used

Main supply isolated

No. of People working^*

Permit Initiator : Department/ Contractor

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with electrical or mechanical work and I comply with all Smart Services safety guidelines.
Name:		Date:^*		Contact:

Energy Isolation Workpermit

1. If the conditions change, stop work immediately and notify PM team and permit shall be automatically void.
2. This permit is valid for one day only. If work needs to be carried out next day, apply fresh work permit.

Document No^*

Permit No^*

Requestor Name^*

Work Location^*

Date of Work^*

Dept./ Company (Contractor)^*

Request for Work Permit Submitted

Time Applied From^*

12 hours format

Time Applied To^*

12 hours format

No. of People working^*

Wireman`s licence available for all

Evidences to be shared

Worker Compensation

Employees State Insurance

Provident Fund

Medical Reports

Gov. ID evidences

Details of electrical/mechanical work to be done^*

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

Mention statutory requirements (If any): ^*

Lock Out Tag Out


	SNO	Energy Type- Electrical or Mechanical	Isolation Point and locks applied	Name of lock applicants	Authorized Signatories

LOTO Checklist

Isolation (LOTO) performed by authorized personnel

Earthing & Discharge provided

Locks used

Are tags properly placed and written

LOTO recorded in logbook

Electrical / Mechanical Work Checklist

Authorised person carryout the work

Electrical/ plumbing /sewer drawing or plan available

Area is barricaded with signage

Electrically insulated tools are used

Main supply isolated

No. of People working^*

Permit Initiator : Department/ Contractor

I fully understand & take responsibility to ensure that the requirements / precautions for this permit have been complied with. I understand the hazards associated with electrical or mechanical work and I comply with all Smart Services safety guidelines.
Name:		Date:^*		Contact:

Extended WorkPermit

Extended Period^*

Reason

Remarks

	Company Name

	Name
	User Id
	Email Id
	User ID / Mobile Number
	Address

	Location
	Pin Code

Welding	Drilling	Gas Cutting
Grinding	Hacking	Others^*

Fire Detection - Smoke Detectors	Water Delivery Systems	Chilled Water System
Security Systems	Exhaust Systems Connected To The Equipment	Drains Connected To The Equipment

Welding	Drilling	Gas Cutting
Grinding	Hacking	Others^*

Fire Detection - Smoke Detectors	Water Delivery Systems	Chilled Water System
Security Systems	Exhaust Systems Connected To The Equipment	Drains Connected To The Equipment

>1.8 meters (6 ft)	Ladder (A Ladder/ Vertical)
Scaffold (on site constructed)	Lifts (scissor lift/Boom lift/Vertical personnel Platform)
Mobile platform (mobile scaffold)	Others^*