Issue Date: 01/07/2016
ISOLATION PERMIT ReviewDate:01/07/2018
This permit is valid for the time specified on the permit and must be
Completed by the person performing the work prior to commencement of any work requiring isolation
Used in conjunction with a SWMS or Safe work instruction
Checked by the GPNSW Representative prior to work commencing
Carried and provided when requested
Provided to the GPNSW Representative on completion of work for sign off
Part A Work Details
Name of permit requestor Business name
Contact Number Date of work
Location of work- Building
room no
Description of work
System to be isolated ☐Gas
☐Electrical
☐other _ provide detail
Note this excludes a Fire Indicator Panel which has a separate permit.
Permit validation period From Date: / / Time:____am/pm To Date: / /Time:____am/pm
GPNSW Authorised Name Permit order number
Representative Position from objective
Part B: Assessment and Controls
Assessment Yes N/A
Safety requirements have been assessed and controls included in safe work method
statements
The energy source can be adequately and safely isolated
Any safety equipment to be used have been maintained and checked prior to use
Persons conducting the work are trained and licenced and competent
There is adequate fire protection for the work being conducted.
Controls Yes N/A
A Work Method Statement has been developed and is specific to and adequate e for the
work to be conducted
Controls in the Work Method Statement are implemented , including (but not limited to)
Lock outs and tags installed to isolated valves or outlets
Fire protection equipment installed
Area barricaded and signed
Working on live electrical installations in accordance with state legislative requirements
Ladders or scaffolds are appropriate for the work, inspected and secure
Persons who made by affected by energy isolation have been notified(eg employees,
customers or contractors)
Part C: Acknowledgement (persons performing the work)
I certify that all necessary precautions as detailed in the permit have been taken to make the area safe for the
permitted work
Contractor Name Company
Signature Date: / / Time:____am/pm
I have reviewed this permit authorisation and authorise the work to proceed as indicated . I confirm that no
conflicting work will be undertaken concurrently with this task
GPNSW Representative Name/Signature Date: / / Time:____am/pm
Persons Entering/Vacating Isolated work area (attach separate sign in sheet if more room required)
Name Company Date Time Time
in out
Custodian: WHS Manager ©GPNSW
Approved by: Place Management Uncontrolled copy when printed Version: 1.1
Number: SMS-02-FM- A1175702 Page 1 of 2
Issue Date: 01/07/2016
ISOLATION PERMIT ReviewDate:01/07/2018
Part D:Completion
I certify the job has been done and the area made safe
Contractor Name Company
Signature Date: / / Time:____am/pm
Site Manager
I acknowledge that the work has been completed and the permit is returned
Name Position
Signature Date: / / Time:____am/pm
Part E. Emergency Authorisation for Lockout release
In the event that the person who put the lock out in place is unable/unavailable to remove the tag and lock, the
following procedure is to be followed to authorise the release of the lockout;
The Authorised Officer and the Contractor have checked
☐The work area is clear of personnel tools and equipment
☐It is safe to remove the tag and lock out device and
☐It is safe to re energise the energy source/re-activate the plant
Name Signature Date Time
Contractor
Authorised Representative
Custodian: WHS Manager ©GPNSW
Approved by: Place Management Uncontrolled copy when printed Version: 1.1
Number: SMS-02-FM- A1175702 Page 2 of 2
