Scribd
Upload
2K views2 pages

Permit To Work Form: Section: Details of Works (Contractor To Complete)

This document is a permit to work form containing details for contractors to complete before performing work. [Section 1] requires information about the contractor, contact details, work description and proposed dates/times. [Section 2] identifies what types of works are involved through a checklist. [Section 3] lists affected services/areas. [Section 4] is for the MVRC office to approve the contractor and check requirements have been met before signing off. [Section 5] is for the MVRC permit number.

Uploaded by

Revelation
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views2 pages

Permit To Work Form: Section: Details of Works (Contractor To Complete)

This document is a permit to work form containing details for contractors to complete before performing work. [Section 1] requires information about the contractor, contact details, work description and proposed dates/times. [Section 2] identifies what types of works are involved through a checklist. [Section 3] lists affected services/areas. [Section 4] is for the MVRC office to approve the contractor and check requirements have been met before signing off. [Section 5] is for the MVRC permit number.

Uploaded by

Revelation
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Permit to Work Form

Section 1: Details of works (Contractor to complete)

Company Name

Contact for Contractor

Phone Number

Description of work

Work Start Date Work Start Time


_______ / _______ / ______ _______________AM / PM

Proposed work end date Proposed Work


_______ / _______ / ______ _______________AM / PM
End Time

Work required to occur out of Work required to


hours (prior to 7am and after Yes / No Yes / No
occur at
5pm) weekends
(please circle) (please circle)

Issuer: (Print Name) Signature

Person carrying out the work Signature


(Print name)

Date permit issued

Copies to be lodged at / with □ MVRC Work location


□ MVRC Maintenance office
□ MVRC Risk and Compliance Manager

Section 2: Works involved


Yes No Comments

Hot Works involved


□ □
Excavation involved
□ □
Has the excavation area involved been
scanned for services □ □
Penetration involved
□ □
Electrical Installation involved
□ □
Gas Installation involved
□ □
Confined Spaces involved
□ □

MVRC Permit to Work Form V1


September 2016
1
Permit to Work Form
Use of Plant involved
□ □
Working at Heights involved (anything over 2
metres)
□ □

Section 3: Services / Areas affected

□ Mechanical lifts / escalators □ Roof □ Fuel Tanks


□ Fire systems □ Workshops □ Chemical storage
□ Water □ Gas isolation □ Electrical isolation

Section 4: Checklist / Permit conditions (MVRC Office use only)


Yes No Comments

Contractor approved
□ □ If not, do not sign PTW

Contractor has QR code – to provide


accreditation □ □ If not, do not sign PTW

All workers for the Contractor have a QR code


– to prove completion of online induction □ □ If not, do not sign PTW

Safe Work Method Statement received


□ □ If not, do not sign PTW

Risk assessment received


□ □ If not, do not sign PTW

Section 4: Permit Status (MVRC Office use only)

The work has been □ Concluded


□ Abandoned
□ Requires an extension
□ Barriers and warning signs remain if work not concluded
□ Tools removed
□ All persons have been withdrawn and warned to cease work in the area
covered by this permit
Permit closed / Authorisation to enter
withdrawn at: Date _______ / _______ / ______

Time _______________AM / PM

Section 5: MVRC Permit Number (MVRC Office use only)

MVRC Permit to Work Form V1


September 2016
2

You might also like