PERMIT TO WORK (P T W)
HIGH VOLTAGE - ELECTRICAL ACTIVITY – ELECTRICALLY DRIVEN EQUIPMENT
PART 1- The Request for a Permit
(To be completed by supervisor or sub-contractors supervisor and submitted to the Approved
Permit Issuer- Engineer – HOD, Supervisor must be in his direct control) )
Name of company
Location of work.
Nature of work to be undertaken including points of isolation, positions of Circuit Main
Earths and which ones may be temporarily removed under IEE rules
Reference of any approved method statement that is relevant to this request
Acknowledgement:
I understand the hazards of this work and the precautions to be taken. I have ensured that
these have been fully explained to the operatives carrying out this work, and consider them
to be competent to do it safely. I will closely supervise these works to ensure that they are
carried out in accordance with the terms of this permit and I will return my copy of this
permit to the Approved Permit Issuer when this work has been safely completed.
Signature: time: Date
PART 2- The Authorization for Work to proceed (to be completed by the Approved Permit
Issuer)
Validation:
I confirm that I have checked that the control measures detailed here in all are in place and
therefore within the limitations below, the equipment / systems described above in section 1
is safe to work on / test
Permit valid from hrs………………on date……………to hrs on date……………….
It is accepted by ………..........(Name- initials - card no.)…………position……contact……
Authorized by………………………………..Approved permit issuer…………….
Time extension from………hrs, on dated………to………hrs on dated………………….
Authorized by……………………………Approved permit issuer……………………
PART 3 – The Cancellation (to be completed by the activity supervisor and / or the Approved
Permit Issuer)
I hereby declare that the work detailed in section 1 has been completed / suspended and
that all persons under my charge have been withdrawn from the specified work area and
warned that this Permit – to - work has now been cancelled and that all tools, additional
earth and all other connections are clear and that the equipment with the exception of that
below is ready for service.
Exceptions:
Signature…………………………supervisor , time hrs………………date……………….
I hereby declare the work undertaken under this Permit has been completed / stopped and
that the permit has been cancelled
Signature……………….......Approved permit issuer………time hrs……….date……………
CHECKLIST FOR PERMIT TO ELECTRICAL, HIGH -MEDIUM LOW - VOLTAGE WORK
(ATTACH SHEET IF REQUIRED)
Control measures (tick if applicable, write n / a if not) √ n / a, not applicable
Approved risk assessment / method statement is attached
Other permits are available (e.g. Utility Provider, etc)
Disconnections done (detail where & how)
Fire / smoke detection equipment disconnected
Apparatus proved dead (detail what tests made below)
Fire extinguishers in place
Adjacent live equipment presents (state precautions taken)
Personal Protective equipment available, active , in use
Danger and caution notices posted (state where)
Access Control (state where displayed)
Atmospheric conditions are humid (state precautions taken if humid)
Temporary lighting available
Earthing is in place (state where apparatus earthed)
Competent person appointed
First aid support available
Safety locks fitted / tagged (LOTO) (specify location)
Emergency procedures in place (specify)
Other precautions (specify)
