Work Permit Format for Safety Management
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ScribdTranslationsWork Permit Format for Safety Management
Translated by
ScribdTranslationsOccupational Health and Safety Management System
LEVEL 7: FORMATS No: FT-SST-093
SG-SST
Date:
WORK PERMIT FORMAT Version: 001
Page 1 of 2
Permission granted from: Date: / / until Date: / / Permission number:
Permission granted to: Height to work:
Sector, Área, Lugar, Tipo de Trabajo, Descripción y procedimiento de latarea:
…………………………………………………………..………………………………………………………………………………………………..
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
Personnel that Executes the Work
Names, surnames and signatures of the Names, surnames, and signatures of the
Identification Identification
Workers Workers
Identify the Hazards
CHEMICALS PHYSICS BIOLOGICAL PSYCHOLOGICAL LABORALS
Solids Noise Animals Content of the task
Liquids Vibration Vegetables Organization of work
Gases and vapors Pressure Virus Human relationships
ERGONOMIC Extreme temperature Bacteria Management
Static charge Ionizing radiation Mushrooms LOCATIVES
Effort Non-ionizing radiation NATURAL Structure installations
Movements ELECTRICS Earthquakes Storage
MECHANICS Hypertension Gales Order of the Yaseo
Tools Mediatension Floods Work at heights
Machines and equipment Low voltage Landslides and slides I work in confined space
Work materials Statics Electric storms
Mechanical transport PHYSICAL SECURITY OTHERS
PHYSICAL – CHEMICAL Attack
Fire Robbery
Explosion Kidnapping
Protection Equipment and Access Systems for Safe Work at Heights
Helmet with chin strap Positioning slings Elevator
Safety glasses Portable vertical lifeline Carabiners
Gloves Fixed vertical lifeline Earplugs
Overall Portable horizontal lifeline Respiratory protection
Safety boots Fixed horizontal lifeline Certified Scaffolding
Full body harness Anchoring adapter Stairs
Fall protection slings Descender
Work Authorization
Responsible DAY1 DAY2 DAY3 DAY4 DAY5
DelC.T.S.A.
Of Work
Start time
Final hour
Date
Prepared: Reviewed: Approved:
Code:FT-SST-093
Modification date:
Occupational Health and Safety Management System
LEVEL 7: FORMATS NO: FT-SST-093
SG-SST
Date:
WORK PERMIT FORMAT Version: 001
Page 2 of 2
DAY1 DAY2 DAY3 DAY4 DAY5
CHECKLISTS
IF NOT IF NOT IF NOT YES NA YES NA
Do the workers have the current payment of social security?
Do the workers have the medical fitness certificate for working at heights?
Workers have the training certificate or competency certificate.
work for preventing falls in high-altitude jobs?
The worker has inspected and reviewed the condition of the system elements.
How to use against falls?
The worker has inspected the access system (certified scaffolding, ladders,
personal elevators, cranes with basket) for working at heights?
Has the condition of the structure been checked before starting the work?
Are the reviewed equipment and/or tools in good condition?
Has the full body harness been installed?
Is there a lifeline with adequate resistance?
Are there anchor points with the adequate resistance?
The staff has been instructed regarding the risks that may arise during
Is this work?
Has the work area been properly defined and isolated?
The worker is wearing all the personal protective equipment according to the
What risks will be exposed?
External factors (weather conditions) allow the work to be done
security?
The workers have completed the health form for work at heights.
The staff has been instructed regarding the use of the equipment for work.
in heights (harness, carabiners, ropes, etc.)
The supervisor is aware of the work and checked the safety conditions.
site before granting permission
OBSERVATIONS
CLOSURE OF THE PERMIT
Height Work Coordinator:................................. Person responsible for the work:....................................
Firma:…………………..……Fecha: / / Hour: Firma:…………………..……Fecha: / / Hour:
Drafted: Reviewed: Approved:
Code: FT-SST-093
Modification date: