Work Block Permit Form
Fill Out Form

Work Block Permit Request

Work Permit Validity

Authorised People

Name & Surname Company Name & Surname Company

PR Approval

Name Date Sign

MCO Approval

Name Date Sign

Pre Task Risk Analysis

Risk Yes/No Risk Yes/No Risk Yes/No Risk Yes/No
Mechanic Risk  Yes  No Lifting Operation  Yes  No Mannual Handling  Yes  No Working at High  Yes  No
Noise/Vibration  Yes  No Confined Space  Yes  No Electrical Risk  Yes  No Electromagnetic Fields  Yes  No
Railways Hitting  Yes  No Toxic Gas/Asphysiating  Yes  No Flammable/Explosive Materials  Yes  No Thermal Energy (Hot Works)  Yes  No
Mechanical Energy (Pressure)  Yes  No Extreme Weather Conditions  Yes  No Artificial Optical Radiation  Yes  No Low Light  Yes  No
Dangerous Checmical Substances  Yes  No Traffic Vehicles  Yes  No Excavation(Burial Risks)  Yes  No

Mitigation Measures to Apply

Measure Yes/No Owner Measure Yes/No Owner
Lock out - Tag out procedure (Attach Lo - To Format)  Yes  No Confined Space Procedure (attach CS Format)  Yes  No
Critical Lifting Procedure (attach critical lifting plan)  Yes  No Firefighting equipment  Yes  No
Implementing measures of work at height  Yes  No Implementing measures for excavation  Yes  No
Work area segrigation and delimitation  Yes  No Removing flammable / toxic / explosive materials  Yes  No
Measure asphyxiating atomspheres / toxic / explosive  Yes  No Install Signs  Yes  No
First aid equipment  Yes  No

Personal Protective Equipment
The applicants will strictly follow the following requirements
1. Access to work will ONLY be in authorised areas.Any changes have to be immediately communicated and previously agreed with the MCD.
2.PR is responsible for clean up after work in the above mentioned area. If any leftovers are in the work area (garbage, debris, tools, equipment, storage, cables etc. ) before he starts his work in the area, he must inform the MCD otherwise he will be kept responsible for the leftovers.

OSO

PR

CSSM-Safety

AUTHORISATION TO START WORK(After verification of all mitigation measure applied by PR and OSO)

 Yes  No

COMPLETION OF THE WORK

 Yes  No

COMPLETION OF THE WORK BLOCK PERMIT

 Yes   No