Safe Work Permit Checklist

This checklist is designed to ensure that all necessary safety precautions are taken before and during work activities that require a safe work permit. It covers key areas to verify that the work environment is safe and that all personnel are aware of the hazards and control measures in place.

Instructions: Complete this checklist before starting any work that requires a safe work permit. Ensure all items are checked and any deficiencies are corrected before work begins. All personnel involved in the work must be familiar with this checklist.

I. Permit Information

• Permit Number:
• Date and Time of Issuance:
• Location of Work:
• Description of Work:
• Permit valid from (Date/Time): ____________ to (Date/Time): ____________ [1]
• Reason for entry: ____________ [2]

II. Hazard Assessment and Control

• Hazards identified and evaluated [1]:
  • Atmospheric hazards (e.g., oxygen deficiency, toxic gases, flammable vapors) 4, 17
  • Physical hazards (e.g., moving machinery, confined spaces, fall risks) 4, 7
  • Other hazards:
• Measures to eliminate or control hazards implemented [1]:
  • Isolation of energy sources (lockout/tagout) 1, 2
  • Ventilation to maintain acceptable atmospheric conditions 4, 11
  • Barriers and shields to protect from external hazards 4, 15
  • Fall protection measures in place [3]
• Acceptable entry conditions verified 1, 2:
  • Oxygen level between 19.5% and 23.5% [4]
  • Flammable gases/vapors less than 10% of LFL [4]
  • Toxic substances below permissible exposure limits [4]
• Testing and monitoring equipment available and calibrated 4, 15
• Results of initial and periodic tests recorded 1, 2

III. Personal Protective Equipment (PPE)

• Required PPE available and in good condition 1, 4:
  • Hard hat
  • Safety glasses/goggles
  • Gloves (specify type):
  • Safety shoes
  • Other (specify):
• PPE properly used by all personnel [3]

IV. Communication and Coordination

• Communication procedures established and understood by all entrants and attendants 1, 10, 14
• Emergency contact information readily available [2]
• Rescue and emergency services identified and available 1, 10
• Procedures for summoning rescue services established 1, 16
• Coordination with other employers (if applicable) 16, 20

V. Personnel and Training

• Authorized entrants listed on permit [2]
• Attendant(s) assigned and aware of duties 1, 13, 14
• Entry supervisor identified and aware of responsibilities 1, 9
• All personnel trained on hazards, entry procedures, and use of equipment 1, 3, 6, 8
• Training records available for inspection [5]

VI. Equipment

• All equipment required for the job is available, inspected, and in good working order 1, 4:
  • Testing and monitoring equipment 4, 15
  • Ventilating equipment 4, 15
  • Communications equipment 4, 15
  • Lighting equipment 4, 15
  • Rescue equipment 4, 15

VII. Permit Sign-off

• All items on this checklist have been verified and completed.
• Work area is safe to proceed.

Entry Supervisor Name: ____________

Entry Supervisor Signature: ____________

Date: ____________

VIII. Cancellation of Permit

• Work completed.
• All personnel and equipment removed from the work area.
• Work area left in a safe condition.
• Permit cancelled.

Entry Supervisor Name: ____________

Entry Supervisor Signature: ____________

Date: ____________

IX. Additional Permits (if applicable)

• Hot Work Permit 1, 6, 19
  • Hot work permit requirements implemented prior to beginning the hot work operations [6].
• Other permits (specify):

X. Notes/Comments:

• Any problems encountered during the entry [7]:

XI. Corrective Actions:

• Deficiencies identified:
• Corrective actions taken:
• Verified by:
• Date:

This checklist is a tool to assist in maintaining a safe work environment. It is not a substitute for proper training, experience, and judgment.