OFS PERMIT TO WORK FORM
Permit to work No: Location Name
Safe work permit Hot work permit Isolation or Lock Out/Tag Out permit
New work Continuation of work
Part 1: To be filled in by person requesting the Permit to Work
Name of person requesting permit Work area
Equipment to be worked on (unit no.)
Work environment (check as applicable):
Over water/unprotected Contaminated atmosphere Explosive atmosphere
Safety systems disabled Confined space Other (specify)
Nature of work to be performed (check as applicable):
Working on safety systems Repairs Maintenance/Inspection Electrical work
Hot work Routine work on hazardous job Non-routine work, no existing procedures
Other (specify):
Safety precautions required for work (check as applicable):
PPE Equipment/Tools
Hard hat Face shield Welding mask Fire detector Fire fighting equipment Gas/O2 analyzer
SCBA Goggles Leather wear Blower/extractor Scaffolding Power tools
Ear protection Rubber gloves/suit Safety line Arc welding Cutting/welding torch Grinder
Safety harness Fall arrestor Work vest/lifejacket Crane Personnel basket Pressure gauge
Survival suit Other (specify) Voltmeter/ammeter Rescue equipment Lock Out/Tag Out
Other (specify):
Safe operating procedures to be used
Mech. Lock/Tag out* Pre-job safety meeting Client authorization Rescue team standby Watchman standby Clear area prior to start
Elect. Lock/Tag out* Restricting access Installing barriers Grounding/bonding Clean,purge equip. Entry/vent locked open
Tank filled with water Depressure equipment Protect fuel tanks Vapor/toxic gas test** Comb. gas test** Oxygen level test**
Qualified electrician High voltage check Contractor orientation Lines carrying HAZMAT isolated
Special procedures(specify what needed & attach procedure):
* Give details of what is to be isloated or Locked/Tagged Out:
** See back of first copy for details of air quality monitoring requirements
Names of persons performing the work: Was each of them briefed? (Yes/No)
Part 2: Approval of Permit I authorize the work to start/continue provided working conditions remain the same. I have checked the safety devices.
Validity: From (date): / / at: hr. min.
To (date): / / at: hr. min. Name and signature of responsible person
Part 3: To be signed only if work completed Part 4: To be signed if work suspended/not completed
The work is completed during the validity, area & equipment restored Permit suspended at: / / at: hr. min.
to safe operating condition. Removal of Lock Out/Tag Out approved. Work stopped, area is secured, isolation & lock out/tag out devices remain installed.
Date: / / New permit is required to resume work. Date: / /
Name and signature of responsible person Name and signature of responsible person
Fig. 12.2 (cont'd)
10 Air quality monitoring requirements.
Does the work require: Continuous monitoring Periodic monitoring at intervals
Initial readings:
Vapor/toxic gas tested for: Allowable exposure limit
Safe working limits: * spark producing work: 0.0% combustible gas
* tank/vessel entry: Oxygen between 19.5% and 21%
* tank/vessel entry: combustible gas maximum 20% of LEL of that product
* toxic gas limits: refer to MSDS
Vapor/toxic gas test Combustible gas test Oxygen test
reading time reading time reading time
Subsequent readings (the following may be used to record additional air quality measurements):
Vapor/toxic gas test Combustible gas test Oxygen test
reading time reading time reading time
