Document No.
FM-HSE-801-003
Revision No. 003
Effective Date 23 JULY 2018
SUPPORTING DOCUMENT Page 1 of 2
TITLE: JOB PERMIT FORM
PART A : JOB PERMIT REFERENCE NUMBER: JP
1) JOBS TITLE Low Risk Jobs High Risk Jobs
a) Maintenance a) Working at height
b) Inspection / survey b) Confined space
2) COMMENCEMENT OF JOBS DATE: / / , TIME: HRS c) Troubleshooting c) Hot work
d) Waste collection d) DG handling
3) ESTIMATED COMPLETION DATE: / / , TIME: HRS e) Civil works e) Lifting activities
f) Mobilization f) Lashing
4) LOCATION g) Ship chandelling g) Electrical
h) Device installation h) Excavation > 1.5m
5) JOBS SCOPE DETAIL i) Cleaning i) Desludging /
j) Others (specify): bunkering
j) Others (specify):
______________________ _______________________
______________________ _______________________
(Requires Permit To Work )
PART B : STATEMENT OF UNDERTAKING
6) PERMIT APPLICANT NAME & NRIC NRIC:
7) DATE & TIME OF APPLICATION DATE: / / , TIME: HRS Checklist (filled by issuing officer on site)
1. Safety briefing ( )
8) CONTACT NUMBER & E-MAIL 2. Wear appropriate PPE ( )
3. Barricade work area ( )
9) DECLARATION
4. Emergency procedure ( )
5. First aid kit ( )
On behalf of (company name) ________________________________________________ 6. Safety signage ( )
declared that I fully understand all the safety requirements and instructions given by 7. Lock out / Tag out (LOTO) ( )
PTP. I hereby take full responsibility for the safety and well being of all person that might be 8. Publish job permit / PTW ( )
directly or indirectly affected / involved by and in this project (project title) 9. PMA/PMT attached ( )
10. Competency certificate ( )
___________________________________________________________________________ 11. HSE Plan submitted ( )
I shall, while undertaking and executing the project, at all time ensuring full compliance to all
safety, health and environment rules, verbal or written instructions, apart from given Do’s & Don’ts for driver
contractually, given by PTP officer from time to time without prior notice, I shall ensure that at 1. Wear seat belt ( )
2. Keep headlights on ( )
no time, any activity, action and event with relation to our project or employees in the project 3. Place beacon light ( )
shall not disrupt or cause delay to the port operations. 4. Obey speed limit / signboard ( )
5. Avoid using hand phone ( )
PERMIT APPLICANT SIGNATURE 6. Parking at designated area ( )
& COMPANY STAMP 7. Follow the traffic flow ( )
8. Give way to RTG in yard ( )
10) TEAM MEMBERS NAME NRIC / PASSPORT MAN HRS CONTACT NUM
SITE MANAGER
SAFETY IN CHARGE
WORKER 1
WORKER 2 Provide attachment if
total of workers are
WORKER 3 more
WORKER 4
WORKER 5
11) VALIDITY (filled by issuing officer) 12) ISSUING OFFICER
NAME :
This permit is issued to _______________________________________ DESIGNATION :
DATE & TIME :
from ____/____/______,_______hrs to ____/____/______,______hrs
subject to the compliance agreed upon by the applicant stated in the SIGNATURE :
Statement of Undertaking by the contractor. & STAMP
Maximum validation for 1 year for contractor that have submitted the
Emergency Contact Number : +607-504 2203
HSE Plan. For enquiries kindly refer to PTP HSE Department office
HSE Officer On Duty : +6019-777 6841
at +607-5042222 ext 5515 / 7732
Document No. FM-HSE-801-003
Revision No. 003
Effective Date 23 JULY 2018
SUPPORTING DOCUMENT Page 2 of 2
TITLE: JOB PERMIT FORM
PART C : JOB SAFETY ANALAYSIS (JSA) JP
JOBS TITLE
SEQUENCE OF JOB STEPS HAZARDS CONTROL MEASURE
