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    Contractor Permit To Work

    Uploaded by

    Andri Mujahidin
    This contractor permit to work document summarizes the details of work to be performed by a contractor at a company location. It includes the contractor company name, workers performing the work, work dates and times, a description of the scope of work, potential risks involved, a contractor declaration confirming qualifications and safety procedures, and authorizations from both the contractor and location supervisor.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Contractor Permit To Work

    Uploaded by

    Andri Mujahidin
    3K views2 pages
    This contractor permit to work document summarizes the details of work to be performed by a contractor at a company location. It includes the contractor company name, workers performing the work, work dates and times, a description of the scope of work, potential risks involved, a contractor declaration confirming qualifications and safety procedures, and authorizations from both the contractor and location supervisor.

    Original Description:

    Contractor Permit to Work

    Original Title

    Contractor Permit to Work

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    © © All Rights Reserved

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    This contractor permit to work document summarizes the details of work to be performed by a contractor at a company location. It includes the contractor company name, workers performing the work, work dates and times, a description of the scope of work, potential risks involved, a contractor declaration confirming qualifications and safety procedures, and authorizations from both the contractor and location supervisor.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    3K views2 pages

    Contractor Permit To Work

    Uploaded by

    Andri Mujahidin
    This contractor permit to work document summarizes the details of work to be performed by a contractor at a company location. It includes the contractor company name, workers performing the work, work dates and times, a description of the scope of work, potential risks involved, a contractor declaration confirming qualifications and safety procedures, and authorizations from both the contractor and location supervisor.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Contractor Permit to Work

    Contractor company name:


    Name of person/s performing
    the work:
    Location of the work:
    Work Start Date: Start Time:
    Work Completion Date: Finish Time:

    Scope of Work to be
    Performed:

    Name of person at {YOUR


    COMPANY} responsible for
    supervising contractor:

    Tasks to be performed include, or could include): (Select all that apply)


    Work in high traffic areas Abrasive blasting Window cleaning
    Hot work (including Use of hazardous Work on or near electrical
    welding, cutting and grinding chemicals (paints, fuels, equipment
    etc) solvents etc)
    Work in areas near Work on Asbestos Use of mobile plant (eg.
    members of the public Containing Materials forklift, crane, vehicle)
    Demolition Erecting scaffolding Confined space entry
    Working at heights >2m (eg. roof work, ladders, cherry pickers, Excavation or trenching
    scissor lift etc) Using power tools
    Other tasks (specify):

    Risk Assessment:
    The hazards involved in this work include:

    How likely is it that an incident would result from this work?


    Unlikely Possible Extremely Likely
    If an incident did occur, what is the likely severity?
    Minor injury or damage Serious injury or moderate Death or major
    damage damage
    Contractors Declaration: Yes No
    Have you provided a Safe Work Method Statement (or other safe work procedure, JSA
    etc) for the work to be performed, which details controls measures for the hazards
    listed above?
    Are you competent to perform the work?
    Have you received relevant training in these tasks?
    Do you hold any relevant licenses for certifications for these tasks?
    Have you completed the {YOUR COMPANY NAME} Insurance Assessment?

    I ________________________________________ of ________________________________________
    (print full name) (print Company name)

    a) understand my duties under Queensland work health and safety laws (including Codes of Practice and
    Australian Standards that are applicable to the work being undertaken) and to the circumstances in
    which the work will be conducted

    b) hold current certification, qualifications and licenses that are required by legislation required for this
    work

    c) have completed the {YOUR COMPANY NAME} site induction

    d) will cease working, make safe the workplace and contact the {YOUR COMPANY NAME} site contact if I
    become aware of danger to myself or others during the period of the work

    e) have a current Workers Compensation and Rehabilitation Insurance Policy in place

    f) agree to comply with all the site safety requirements and reasonable directions given by {YOUR
    COMPANY NAME}.

    Signature: Date:

    {YOUR COMPANY NAME} Permit to Work Authorisation:


    This work is authorised to proceed from:
    Permit Start Date: Start Time:

    Permit Completion Date: Finish Time:

    Name: Signature:

    To be signed off by {YOUR COMPANY NAME} upon completion of the works:

    I have inspected the work and the work area, and believe to the best of my knowledge, that the work has
    been completed safely and the work area left in a safe state.

    Name: Signature:

    Date: Time:

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