Work Permit Certification Procedure and Format

I have attached a rule and regulation manual where the permit conditions are mentioned.

      To be filled in by Job Supervisor/ Engineer
Permit Valid from …………….. To …………., if Job supervisor changed then their signature should be incorporated in the format
Job Executor Name: Sig.: Date: Time: Department:
Description of work
Equipment No
A Action Taken by Executor : Please write Yes or No in the box provided.
Sr.No. Hazard Identification Yes/No Remarks
1 Electrical
2 Confined area
3 Height Work
4 Hot Work
5 Excavation work
6 Mobile Crane
7 Compressed Air
8 Hydraulics
9 Any Other
B PPE Required : Please write Yes or No in the box provided.
Sr.No. PPE Yes / No Sr.No. PPE Yes / No
1 Full Body Harness 5 Hand Gloves
2 Ear Plug 6 Apron & Leg Guard
3 Goggle / Face shield 7 Heat Resistance suit
4 Dust Mask 8 Any Other
C Permits Required : Please write Yes or No in the box provided.
Sr.No. Safety Checks for compliance Yes/No If Yes,     Permit No. Remarks
1 Is Electrical Work Permit Required ?
2 Is Confined area permit required ?
3 Is Height Work Permit Required ?
4 Is Hot Work Permit Required ?
5 Is Excavation work permit required ?
6 Is Process Isolation required ?
If YES, take clearance form process Dept.
Name of Concerned Process Engineer Signature & Date
Permit Issuer Name Signature Date Time
Concerned Engineer
Concerned SH
 Acceptance: To be completed by the person who will carry out the job. Then to be handed back to issuing person.
I understand the work which is to be carried out and the method of work to be used to ensure that it is carried out safely . Signature:                Date:             Time:
(Job Supervisor/Contractor )
No work will be carried out other than the work authorized by this permit
Extension / Transfer of permit All checks reviewed & found OK to extend permit Remarks
Date Signature Date Signature Date Signature Date Signature Date Signature
Job Supervisor
Concerned Engr.
Concerned SH
Completion: The above work is completed. Man power deployed is removed from the working site. Signature:                Date:             Time:
(Job Supervisor/Contractor )
Note : 1. This permit Applies only to work in the location described.
2. This permit only applies to the person to whom it is issued. If work has to be continued by someone else, this permit must be returned to issuer for cancellation and another permit issued.
Copy  :(1) Job Sup./Contractor (2) Safety Office, (3) Office Record ( Retention Period 7 days)


Click Here To Download General Work Permit

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