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Permit To Work - Periodic Check For High Risk Activity

This document is an attachment to a Permit to Work that outlines the periodic checks required for high-risk activities. It includes sections for supervisors and authorized personnel to confirm safety measures, workplace conditions, and control measures are in place. The document provides spaces for multiple checks, signatures, and comments, emphasizing the importance of ongoing safety verification.

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Amit Kumar
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136 views5 pages

Permit To Work - Periodic Check For High Risk Activity

This document is an attachment to a Permit to Work that outlines the periodic checks required for high-risk activities. It includes sections for supervisors and authorized personnel to confirm safety measures, workplace conditions, and control measures are in place. The document provides spaces for multiple checks, signatures, and comments, emphasizing the importance of ongoing safety verification.

Uploaded by

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

Attachment to Permit to Work


Periodic Check for High-Risk Activity

By signing this sheet, the work supervisor and GE System Owner, Permit Issuer or other GE authorized person confirm the
following:
- the high-risk activity is still performed as per the description / limitations of the PTW,
- there are no changes in the workplace conditions that could significantly affect safety of the work,
- all control measures identified in the PTW and associated risk assessment are effectively in place.
Type of check:  Daily  Shift  Non-routine lift Date and Time:
Work Supervisor

Check #1
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorised Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #2
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #3
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #4
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor Check #5
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor
Check #6

Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

4. PERMIT TO WORK -PERIODIC CHECK FOR HIGH RISK ACTIVITY Page 1 of 5


Refer to PTW#
Attachment to Permit to Work
Periodic Check for High-Risk Activity

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #7
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #8
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #9
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #10
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #11
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor
Check #12

Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

4. PERMIT TO WORK -PERIODIC CHECK FOR HIGH RISK ACTIVITY Page 2 of 5


Refer to PTW#
Attachment to Permit to Work
Periodic Check for High-Risk Activity

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #13
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #14
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #15
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #16
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #17
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor
Check #18

Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

4. PERMIT TO WORK -PERIODIC CHECK FOR HIGH RISK ACTIVITY Page 3 of 5


Refer to PTW#
Attachment to Permit to Work
Periodic Check for High-Risk Activity

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #19
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #20
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #21
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #22
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #23
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor
Check #24

Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

4. PERMIT TO WORK -PERIODIC CHECK FOR HIGH RISK ACTIVITY Page 4 of 5


Refer to PTW#
Attachment to Permit to Work
Periodic Check for High-Risk Activity

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #25
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #26
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #27
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #28
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor

Check #29
Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

Type of check:  Daily  Shift  Non-routine lift Date and Time:


Work Supervisor
Check #30

Full name: Signature: Comments:

 GE System Owner  Permit Issuer  other Authorized Person


Full name: Signature:

4. PERMIT TO WORK -PERIODIC CHECK FOR HIGH RISK ACTIVITY Page 5 of 5

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