SmartCheck | COMPUTERISED MAINTENANCE MANAGEMENT SYSTEM

Raise WorkPermit

Select Department^*

Select Asset^(Optional)

Select Sub Asset^(Optional)

Name of the Person Raising/Initiating permit^*

Emp.I.D No^*

Permit No^*

LOTO No^*

Identification of task^*

Building Name and Job Location^*

Equipment/System^*

Description of work to be carried out^*

Work to be Carried^*

Attended By^*

Permit Requirements and Validity

No. of persons permitted to work^*

Start Date^*

Start Time^*

12 hours format

Period of Work^*

WorkPermit Priority^*

WorkPermit Type^*

Hazards involved, and precautions taken in the course of work
Hazards	Status	Precautions to be taken
Chances of Electrical Shock
Chances of Trip, Slip & Fall
Chances of falling objects
Chances of vibration and Noise
Chances of Extreme Weather
Awkward Posture of workers
Chances of Manual Handling
Chemical handling and use
Chances of excess Dust and Fumes
Chances of bacterial infection
Others, if any

The area has been examined and the following precautions taken		Remarks
A. Equipment/System isolated and free from flammable liquid, dust and oily deposits
B. 11mtrs area free and secure from flamm ability/Please indicate the free distance available.
C. Room/Working place Air quality should be checked for flammability (LEL) (for covered area)

Hazards involved, and precautions taken in the course of work
Hazards	Status	Precautions to be taken
Power cables at the vicinity
Presence Combustible materials
Presence of Flammable gas cylinders
Lack of ventilation at the area
Chances of Non-ionizing radiation
Generation of Excess Sparks & Toxic Fumes
Chances of Oxygen Depletion
Unsafe/Confined working area
Others, if any

Identified Hazards	Status	Precautions to be taken
Slip, Trip & Fall Hazard
Chances of Toxic Fumes
Chances of Falling Objects
Moving Parts of Equipment& Machinery
Poor Visibility
Presence of Water and Risk of Drowning
Chances of Temperature Extremes
Chances of excess Noise
Substance entering through piping
Chances of Electrical Shock
Chances of Chemical use for disinfection
Additional Precautions Taken		Remarks
Are All affected persons informed?
Is there an assigned attendant outside the confined space to only monitor & coordinate the activity?
Are the persons who are entering confined space is wearing safety belt and another end is handled by standby person/Buddy/Attendant?

Hazard Environment Monitoring

Oxygen

Flammability

H2S

CO

In case of any Isolation, Specify particulars

In case of scaffolding		Remarks
Is the scaffolds strong enough for the loads and tied to a building or rigid point
Are the scaffolds a safe distance from the power lines
Are the scaffolds easily accessible?
Is climbing personsshoes checked for mud, paint, oil or otherslick/stick substances
In Case of Ladder		Remarks
Is the work area clean from spill age of oil, water or any other liquid & floor levelness?
Maintain at least 3-point contact with ladder (while climbing or work)
Workers should face ladder when climbing, descending or working from ladder
The ladder should be at least one feet extra than the point of contact at the top
In Case of Harness(Note: Fully Body Harness Must be used)		Remarks
Check for safety certificate and validity of the full body harness
Check for any damage/Cutsin D-Rings, Buckles, Keepers, Back pads and belts
Additional precautions: Take trained rescue team support in case of height worker met with free fall & suspension

Name of the buddy

Emergency Contact No

Hazards involved, and precautions taken in the course of work
Hazards	Status	Precautions to be taken
Fragile Work Platform
Sloppy Work Platform
Extreme weather conditions
Falling Objects/Materials
Protruding Sharp objects
Overhead power lines
Others, if any

Electrical work
PRECAUTION OR SPECIFIC REQUIREMENTS
Availability of LOTO procedure			Usage of 3 pin sockets in all Electrical appliances
Qualified Electricians			Availability of Electrical safety gloves
No physical damage in the wires			Electrical Insulation mats in the area of work
Area of work is free of water			Usage of proper PPEs (Safety Shoes, gloves, etc.)
Follow up of earthing practices			Warning Signages
Usage of Insulated tools			Line clearance obtained

Scaffold Workpermit
Are barriers or guardrails in place where work will be within two (2) metres of the edge?			Has gradient, height, access and load, been considered for the of scaffolding position?
Are lanyards or other measures in place to prevent tools and equipment falling from heights			Confirm that the person erecting the scaffolding is trained?
Has the area around the work area been cordoned off and signposted?			Have operator's ladders and guard rails been erected to prevent fall?
Do weather conditions (such as strong winds, rain, heat, glare or electrical storms) present a hazard?			If persons and/or vehicles are in close proximity, controls in place?

Are operators equipped with good condition and compatible personal protective equipments for safety harness and rope grab?			Is the gandola in working condition are they checked and ensured safety of equipment to work?
Is the control box in the Gondola covered and locked?			Is the person working on gandola is competency and licenced?
Is the worker has covered with the insurance,If so is the insurance valid?			Are ground floor barricaded with proper access & signage?
Do weather conditions (such as strong winds, rain, heat, glare or electrical storms) present a hazard?			Are the signboard "safe working load (maximum 300kg)" and "maximum allowable number of operators (not more than 2 persons)" prominently displayed on the cradle?
Specific Precautions : Refer factories Act 1948, Rule 61-A & Rule 61-C where any person is required or allowed to work allotted to work at a place from which may be liable to fall through a distance of more than TWO METERS, he should wear safety harness which should be secured or hooked to some rigid fixture. The safety harness so provided should be treated and examined through by a competent person at least once in six months and certified with regard to its suitability to be obtained.

Excavation WorkPermit
Proposed / Expected excavation plan Land mark:
Length	Width	Depth
Has a current drawing / layout indicating the position of underground service marked ?
Mark a tick for the underground service affected due to this excavation work
Electricity	Water	Sewage
Fire hydrant	Data/ Network	Land scaping
Special Precaution advice to the work executing contractor :

1. Under no circumstances the permitted work should be carried out after the closing time defined in this work permit.
2. Permit should be returned to the initiator on completion of work.
3. This permit is to be issued for defined scope of work and valid for a maximum period of 7days.
4. Take Reference permits for simultaneous (Multiple) works eg. Electrical work at height.

HAZARDS, PRECAUTIONS TAKEN & PPE's

Falling Objects

Hardhacks

Fatigue

Low Visibility

Stress

Drowsy

Improper Monitoring

Person Falls

Depression

OTHER HAZARDS

PRECAUTIONS TAKEN

Work area Lighting

Safe Routes

Safe Access/Egress

Separate Vehicle & Worker Path Ways

HIRA Undertaken

Signage's Provided

SOP

Reflection Vests

Trainings

Blinkers

OTHER PRECATIONS

PPE is REQUIRED

JOB SPECIFIC PPE's:

Safety Helmet

Safety Shoes

Full Body Harness

Cover All

High Visibility Vest

OTHER PPE'S:

SAFETY CONSIDERATIONS TO BE CHECKED AT SITE
Description	MON	TUE	WED	THU	FRI	SAT	SUN
Is sufficient Illumination to be provided
Is security notified of night work
Is medical aid resources available
Availability & Use of PPE's
Proper Housekeeping to be done on daily basis
Any other requirement (If Yes, please specify): Emergency exit are available, Emergency vehicle and First-aid provider shall be assured during the work Main Isolation Switch location is known to All
Use of Full body harness with double lanyard & life line or anchor point (while doing hot work at height)

REVALIDATION AND RENEWALS OF WORK PERMIT

DATE	SHIFT	ISSUER Department/Tower/Work In-charges			Contractor Project In-charge(Requestor)			REQUESTOR Client/Contractor(Engineer/Supervisor)			SAFETY DEPARTMENT
DATE	SHIFT	NAME	SIGN.	TIME (hrs)	NAME	SIGN.	TIME (hrs)	NAME	SIGN.	TIME (hrs)	NAME	SIGN.	TIME (hrs)
DAY - 1	A/G
	B
	C
DAY - 2	A/G
	B
	C
DAY - 3	A/G
	B
	C
DAY - 4	A/G
	B
	C
DAY - 5	A/G
	B
	C
DAY - 6	A/G
	B
	C
DAY - 7	A/G
	B
	C

Protective equipment required
Safety Shoes	Safety Goggles	Safety Helmet	Safety Hand Gloves	Safety Masks
Ear Muff/Ear Plugs	Safety aprons	Safety body suit	Face shield	Full Body Harness
Hard hats	Respiratory Protective Equipment	Safety Belt	Others

Team is Aware of the jobs to be carried out, hazards involved, and the above permit conditions are adhered

In case of any Emergency, emergency Contact No
Aware of the jobs to be carried out, hazards involved and ensured that all the safety conditions are adhered
Checked by	Sign		Date/Time
Permit received by	Permit issued by		Authorized by

PERMIT CLOSURE
The work is completed: No incidents/accidents observed, all men, materials have been removed from the work place.
Remarks
Permit Returned By		Permit Closed by
Date and Time		Date and Time

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