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Permit to Work Form Template

The document is a Permit To Work Form used by Xindeco IOT Malaysia Sdn. Bhd. to ensure safety and compliance during various types of work activities. It includes sections for detailing the work, involved personnel, type of work, service disruptions, PPE requirements, and work requirements. The form also contains a contractor declaration and sections for permit approval and completion of work declaration.

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ainaabhar00
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58 views1 page

Permit to Work Form Template

The document is a Permit To Work Form used by Xindeco IOT Malaysia Sdn. Bhd. to ensure safety and compliance during various types of work activities. It includes sections for detailing the work, involved personnel, type of work, service disruptions, PPE requirements, and work requirements. The form also contains a contractor declaration and sections for permit approval and completion of work declaration.

Uploaded by

ainaabhar00
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

DOC NO.

REV A1
Permit To Work Form
PAGE 1/1
EFFT. DATE

Details of work
Company: Date:
Name: IC:
(Leader/Supervisor)
Location: Phone No.:
Name of Involved Person
1) 4)
2) 5)
3) 6)
Type of work (Tick Whichever is applicable)
Welding Working at Height Construction work
Drilling Electrical work Use of heavy machine
Grinding Maintenance work Others;
Service Disruption (Tick Whichever is applicable)
Domestic Water Electric supply Production Machine
Internet/Server Road/Access Air conditioner
PPE Requirements (Tick Whichever is applicable)
Safety Helmet Earplug/Earmuff Glove
Safety Glass Apron Safety shoes
Face Shield Respirator/face mask Others;
Work Requirements (Tick Whichever is applicable)
Warning Signs Barricade Power tools
Ladder Hand tools Heavy Machinery
Contractor Declaration
☐ I hereby declare that I have read, understood and will comply with all safety, health,
environmental and security rules of Xindeco IOT Malaysia Sdn. Bhd. while performing any work
within the premises.
☐ I further agree that I shall be fully responsible and liable for any accident, injury, damage or
incident arising from my own negligence, misconduct, or non-compliance with company rules,
regulations, and statutory requirements

Name: Signature:
Permit Approval Approve Reject
Name: Signature:
Completion of work declaration
Contractor Company Representative
Name: Name:
Signature: Signature:

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