This form supports a competent process, it does not replace one
A permit is only as good as the person issuing it. Permits must be issued by someone competent and authorised for that class of work, based on a task-specific risk assessment. This template gives you the structure and the audit trail. It does not substitute for training, licensing, isolation procedures, atmospheric testing or equipment inspection, and it does not make an unsafe job safe.
Where a specific permit type applies, use it instead of this one. Confined space entry and hot works both have their own forms in this library.
Permit details
Hazards identified for this task
- Stored energy: electrical, mechanical, hydraulic, pneumatic, thermal, gravitational
- Live services in the work area, including buried or concealed services
- Fall from height, or falling objects onto people below
- Confined space or restricted egress
- Hot work, ignition sources or flammable atmosphere
- Hazardous chemicals, dust, fumes or asbestos-containing material
- Plant or vehicle movement in or near the work area
- Interaction with other trades, our operations, or the public
- Work outside normal hours, alone or in an isolated area
- Noise, temperature extremes or poor lighting
Isolations and controls in place before work starts
Every isolation is verified by test, not by assumption that the switch did what the label says.
| Energy source or hazard | Isolation point | Method (lock, tag, blank, drain) | Verified de-energised by | Time | Lock or tag number |
|---|---|---|---|---|---|
Additional controls required
- Area barricaded and signed, with the exclusion zone sized for the hazard
- Fire extinguisher or spill kit present and appropriate to the task
- Ventilation or extraction in place and running
- Atmospheric testing completed where required, with results recorded on the relevant permit
- Rescue arrangements agreed and resourced before entry or ascent
- Standby or observer person appointed and briefed
- Communications tested between the work party and the standby person
- Emergency contact and escalation path confirmed, including how to call 999
- Affected staff, occupants or the public notified
- PPE specified for the task available, inspected and correctly fitted
Authorisation
Three signatures, three different roles. The issuer authorises, the acceptor takes responsibility for the work party, and the area owner confirms the wider site is ready.
| Role | Name | Signature | Date and time |
|---|---|---|---|
| Permit issuer (authorised person) | |||
| Permit acceptor (person in charge of the work) | |||
| Area or asset owner |
Suspension and re-validation
Use this if work stops and restarts within the permit period, for example over a meal break or a shift handover.
| Suspended at | Reason | Conditions left in place | Re-validated at | Re-checked by |
|---|---|---|---|---|
Hand-back and close-out
The permit is not finished until this section is signed. An open permit means the isolation is still assumed to be in place.
- Work is complete, or has stopped and the area made safe
- All tools, materials and waste removed from the work area
- Guards, covers, handrails and interlocks refitted and secured
- All locks and tags removed by the people who applied them
- Systems restored and function tested where required
- Barricades and signage removed
- Area inspected and returned to the area owner
- Any outstanding defect or follow-up recorded and reported