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1. Y N
1
1.1
1.2
1.3
1.4
2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
3
3.1
3.2
3.3
4
4.1
4.2
4.3
Administration and Organization
Is the form properly filled-up and signed?
Copies of PTW available : Original (Worksite), Copy 1
(Control Room/PTW Office/Station), Copy 2 (RA)
Are personnel involved in PTW trained, assessed and
appointed?
CHECKLIST FOR PERMIT TO WORK
NO WORK IS SO URGENT THAT WE CANNOT TAKE TIME TO DO IT SAFELY
No Check List
Compliance
REMARK
Has the work been hand back and PTW signed off by RA
and AA upon completion of the job?
Has the housekeeping been done after completion of the
job?
Are incompatible activities e.g. atmospheric venting,
draining, line breaking, sampling been prohibited at
adjacent areas?
Are firefighting equipment e.g. fire extinguisher, fire
blanket available and working?
Is the work description clear and specific (e.g. exact
location, equipment)?
Have all hazards associated with the work been
identified and necessary precautions specified ?
Are personnel using correct PPE specified in PTW?
Are the supporting certificates, JHA/JSA and relevant
drawings for the work attached with the PTW?
Has joint-site inspection been conducted by AAR and
RAR and WL
Has toolbox talk been conducted for the work?
Hot Work
Implementation & Monitoring
Is the list of PTW authorized signatories updated and
displayed at the PTW Office/Station?
Gas Testing
AA (Approving Authority), AAR (Approving Authority Representative), RA (Receiving, authority)
RAR (Receiving Authority Representative), WS (Work Supervisor), WL (Work Leader)
Percentage Compliance (Total no complied/Total no of requirements) %
Is the assigned fire-watch present at site?
Are the AGTs certified?
Is the gas testing frequency specified on the PTW and
carried out i.e. Continuous or at specified intervals?
Have the Gas testing meters been calibrated and valid?
Has revalidation been carried out during shift change or
if there is any change to the conditions of the permit?