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    Routine Maintenance Safe Work Permit-General

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    Vel Murugan
    This document is a routine maintenance safe work permit for a retail site. It requires identification of hazards associated with the planned work. Any elevated or high risks require a job safety analysis to be completed on the reverse side describing hazards, controls, and emergency response. Basic safety requirements and personal protective equipment must be confirmed. Workers and supervisors must acknowledge the planned work. The permit does not apply for work involving more than 6 workers, taking more than 10 days, or classified as high risk.

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    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd

    Routine Maintenance Safe Work Permit-General

    Uploaded by

    Vel Murugan
    1K views3 pages
    This document is a routine maintenance safe work permit for a retail site. It requires identification of hazards associated with the planned work. Any elevated or high risks require a job safety analysis to be completed on the reverse side describing hazards, controls, and emergency response. Basic safety requirements and personal protective equipment must be confirmed. Workers and supervisors must acknowledge the planned work. The permit does not apply for work involving more than 6 workers, taking more than 10 days, or classified as high risk.

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    This document is a routine maintenance safe work permit for a retail site. It requires identification of hazards associated with the planned work. Any elevated or high risks require a job safety analysis to be completed on the reverse side describing hazards, controls, and emergency response. Basic safety requirements and personal protective equipment must be confirmed. Workers and supervisors must acknowledge the planned work. The permit does not apply for work involving more than 6 workers, taking more than 10 days, or classified as high risk.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views3 pages

    Routine Maintenance Safe Work Permit-General

    Uploaded by

    Vel Murugan
    This document is a routine maintenance safe work permit for a retail site. It requires identification of hazards associated with the planned work. Any elevated or high risks require a job safety analysis to be completed on the reverse side describing hazards, controls, and emergency response. Basic safety requirements and personal protective equipment must be confirmed. Workers and supervisors must acknowledge the planned work. The permit does not apply for work involving more than 6 workers, taking more than 10 days, or classified as high risk.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 3

    ROUTINE MAINTENANCE SAFE WORK PERMIT (SHELL)

    (See Condition of Use on Reverse)


    Date: W/O No: Description of Planned Work: Site No: Prime Contractor: Completed By:

    Note: Record any significant unusual or unexpected e ents on re erse!

    Su"contractor#s$:

    SECTION A: HAZARD IDENTIFICATION AND CONTROL W%ere t%e follo&ing ele ated risk site %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
    O er%ead Po&er 'ines ,raffic -a.ardous /aterial #)uel+ 0s"estos+ ,oxic C%emical+ )reon+ etc!$ 1nclement Weat%er #specify$: /o"ile -ea y (2uipment 0cti ity #Boom ,ruck+ Scissor 'ift$ Welding+ Cutting+ *rinding in non4%a.ardous atmosp%ere (xca ation less t%an 5!6m Potential (nergy #)luid or *as under Pressure+ (lectricity$ Slip/,rip Ot%er #specify$:

    W%ere t%e follo&ing ele ated risk &ork %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
    )uel Pressure/3acuum ,esting Coordination 1nterdependency #O erlapping ,rades$ Ot%er #specify$:

    W%ere t%e follo&ing %ig% risk &ork %a.ards exist+ t%e applica"le critical task c%ecklist or procedure must "e completed and incorporated into '0e 5SA on t%e re erse
    Work at -eig%t a"o e 7!6m Confined Space (ntry #S,P Sump+ Car Was% Sump+ etc!$ 'ock Out/,ag Out (2uipment 1solation Re2uired 8se of 3acuum ,ruck Cutting+ *rinding in %a.ardous atmosp%ere Critical Controls affected #'eak Detection+ 3ideo 'oss+ etc!$ -ea y (2uipment 'ifting #i!e!+ &it% Crane or Boom ,ruck$ Ot%er #specify$:

    SECTION B: CONFIRMATION OF BASIC REQUIREMENTS


    Work &ill "e conducted in accordance &it% applica"le O-9S regulations and Prime Contractor:s Safety Policy! W-/1S Re2uirements are met+ if applica"le! 0ppropriate Personal Protecti e (2uipment &ill "e used "y Workers and 3isitors in Work 0rea! Certified appropriate )ire (xtinguis%er#s$ are a aila"le in Work 0rea+ if applica"le! ,ools and (2uipment to "e used are appropriate and in good &orking Condition! 0ll &orkers are ade2uately trained for t%eir ,asks!

    T!!) 4E6uip"e$' '! .e u e( '0#' #re Re)ev#$' '! S#&e'% 'Ladder, (arricades, Tri)od, %arness, *orta$le +as Monitor, etc&,:

    A((i'i!$#) PPE Re6uire"e$' 7 i& A$% 'at Minimum: Safety (oots#%ard %at#-isi.-est#Safety +lasses#+lo/es Fit for 0se,:
    Ot%er (ye Protection #specify$: -earing Protection Ot%er #Specify$: )all Protection Breat%ing 0paratus/Dust /ask

    SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTIN- RESULTS '*eriodic,


    Supervi !r C!"p#$% N#"e Cr#&' !r Tr#(e Te ' Re u)' (N!* !u' !& +) Supervi !r Si,$#'ure

    ***Four criteria for testing LRMA quality: understands task, risk identification, adequate risk mitigation and attitude

    SECTION D: ACKNOWLED-EMENTS OF PLANNED WORK


    Name: Re p!$ i.)e Te/0 1 Re p!$ i.)e Te/0 2 Re p!$ i.)e Te/0 3 Person completing ,%is Permit #Named 0"o e$ Signature:

    RETAILER4SALES ASSOCIATE:
    Signature

    am/pm Work Start Time

    am/pm Signature Finis Time

    N!T": T e Retailer#SA Assumes No Lia$ility for t e %ealt and Safety of t e Workers&

    CONDITION OF USE: THIS FORM IS APPLICABLE DAIL8 FOR ALL RETAIL MAINTENANCE WORK E9CEPT FOR THE FOLLOWINSITUATIONS7 IN WHICH CASE A POST SAFE WORK PERMIT FORM MUST BE USED: 4 /ore t%an ; tec%nicians/trades at one time+ up to a maximum 6 &orkers at one time including %elpers+ or 4 Work expected to re2uire more t%an < days to complete+ or 4 Work &it%in a fenced area+ or 4 -ig% Risk Work #demolition+ exca ation greater t%an 5!6m+ confined space entry except S,P sumps+ open flame in %a.ardous area+ erection of structures$!

    5OB SAFET8 ANAL8SIS (5SA)


    H#:#r(!u A/'ivi'% '!rder in 1 ic t e 1ork 1ill $e carried out and $rief details of o1 tasks 1ill $e )erformed,& P!'e$'i#) H#:#r( '"2am)les: electric s ock, fall, fire, cut, /e icle im)act, c emical s)las , as) y2iation, critical control $y)assed, etc&, S#&e'% C!$'r!) '! Re(u/e !r E)i"i$#'e H#:#r( '3escri$e t e )recautions t at 1ill $e taken,

    7 < ; = 6 > ? @
    Si,$i&i/#$' u$u u#) !r u$e;pe/'e( eve$' e$/!u$'ere( (uri$, <!r=7 i& #$%:

    ROUTINE MAINTENANCE SAFE WORK PERMIT


    (See Condition of Use on Reverse)
    Date: W/O No: Description of Planned Work: Su"contractor#s$: Site No: Prime Contractor: Completed By:

    Note: Record any significant unusual or unexpected e ents on re erse!

    SECTION A: HAZARD IDENTIFICATION AND CONTROL W%ere t%e follo&ing ele ated risk site %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
    O er%ead Po&er 'ines ,raffic -a.ardous /aterial #)uel+ 0s"estos+ ,oxic C%emical+ )reon+ etc!$ 1nclement Weat%er #specify$: Potential (nergy #)luid or *as under Pressure+ (lectricity$ Slip/,rip Ot%er #specify$:

    W%ere t%e follo&ing ele ated risk &ork %a.ards exist+ '0e 5SA on t%e re erse must "e completed:
    /o"ile -ea y (2uipment 0cti ity #Boom ,ruck+ Scissor 'ift$ Welding+ Cutting+ *rinding in non4%a.ardous atmosp%ere (xca ation less t%an 5!6m )uel Pressure/3acuum ,esting Coordination 1nterdependency #O erlapping ,rades$ Ot%er #specify$:

    W%ere t%e follo&ing %ig% risk &ork %a.ards exist+ t%e applica"le critical task c%ecklist or procedure must "e completed and incorporated into '0e 5SA on t%e re erse
    Work at -eig%t a"o e 7!6m Confined Space (ntry #S,P Sump+ Car Was% Sump+ etc!$ 'ock Out/,ag Out (2uipment 1solation Re2uired 8se of 3acuum ,ruck Cutting+ *rinding in %a.ardous atmosp%ere Critical Controls affected #'eak Detection+ 3ideo 'oss+ etc!$ -ea y (2uipment 'ifting #i!e!+ &it% Crane or Boom ,ruck$ Ot%er #specify$:

    SECTION B: CONFIRMATION OF BASIC REQUIREMENTS


    Work &ill "e conducted in accordance &it% applica"le O-9S regulations and Prime Contractor:s Safety Policy! W-/1S Re2uirements are met+ if applica"le! 0ppropriate Personal Protecti e (2uipment &ill "e used "y Workers and 3isitors in Work 0rea! Certified appropriate )ire (xtinguis%er#s$ are a aila"le in Work 0rea+ if applica"le! ,ools and (2uipment to "e used are appropriate and in good &orking Condition! 0ll &orkers are ade2uately trained for t%eir ,asks!

    T!!) 4E6uip"e$' '! .e u e( '0#' #re Re)ev#$' '! S#&e'% 'Ladder, (arricades, Tri)od, %arness, *orta$le +as Monitor, etc&,: A((i'i!$#) PPE Re6uire"e$' 7 i& A$% 'at Minimum: Safety (oots#%ard %at#-isi.-est#Safety +lasses#+lo/es Fit for 0se,:
    Ot%er (ye Protection #specify$: -earing Protection Ot%er #Specify$: )all Protection Breat%ing 0paratus/Dust /ask

    SECTION C: LAST MINUTE RISK ASSESSMENT (LMRA) TESTIN- RESULTS '*eriodic,


    Supervi !r C!"p#$% N#"e Cr#&' !r Tr#(e Te ' Re u)' (N!* !u' !& +) Supervi !r Si,$#'ure

    ***Four criteria for testing LRMA quality: understands task, risk identification, adequate risk mitigation and attitude

    SECTION D: ACKNOWLED-EMENTS OF PLANNED WORK


    Name: Re p!$ i.)e Te/0 1 Re p!$ i.)e Te/0 2 Re p!$ i.)e Te/0 3 Person completing ,%is Permit #Named 0"o e$ Signature:

    RETAILER4SALES ASSOCIATE:
    Signature N!T": T e Retailer#SA Assumes No Lia$ility for t e %ealt and Safety of t e Workers&

    am/pm Work Start Time Signature Finis Time

    am/pm

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