COMPANY NAME: CONTROL SHEETS & FORMS GENERAL PERMIT TO WORK .

Permit to Work No. -1- General Information

Personnel involved: Task Identification: Location of Site: Equipment to be Used: (Specify)

-4- Additional Precautions

-5- Duration of Permit to Work -2- Supporting Documentation

Method Statement Risk Assessment COSHH Assessment Other (Specify) Date: Start Time: Finish Time: THIS PERMIT IS ONLY VALID FOR THE TIME SPECIFIED

-6- Competent Person

Note: It is the responsibility of the Competent Person to ensure that the personnel involved in carrying out the work fully understand the detail and requirements laid down on this permit. Name: Signature: Date: Time:

-7- Issuing Authority -3- Task Classification

Cold Work Confined Space Hot Work Electrical Other(Specify) MONITORING RESULTS AND OR ISOLATIONS TO BE RECORDED ON THE REVERSE SIDE OF THIS PERMIT Name: Signature: Date: Date: Date: Time: Time: Time:

-8- Cancellation
Competent Person Signature: Issuing Authority Signature:

The Royal Bank of Scotland Mentor Services

CONTROL SHEETS & FORMS

Monitoring Results/Isolations as necessary

A (3) 1.016

Electrical Isolations

Atmospheric Checks

Other (Specify)

The Royal Bank of Scotland Mentor Services

CONTROL SHEETS & FORMS

Guidance for Completion of the Permit - to - Work -1- General Information
The name of the personnel carrying out the work must be stated. Task Identification: The nature of the work being carried out by the personnel must be stated. Location of Site: The exact location where the work is being carried out must be stated. Equipment to be Used (Specified): Plant and equipment which will be used during the task must be stated.

A (3) 1.016
-4- Additional Precautions
Precautions in addition to those stated in the method statements, risk assessments and COSHH assessment must be stated here.

-5- Duration of Permit to Work

The duration of the Permit to Work must be stated here including the date, starting time and finishing time of the task (identified in section 1). -6- Competent Person

-2- Supporting Documentation

Method Statement: The reference number/title of the method statement which relates to the task (identified in section 1) must be stated here. Risk Assessment: The reference number/title of the risk assessment which relates to the task (identified in section 1) must be stated here. COSHH Assessment: The reference numbers of the COSHH (Control of Substances Hazardous to Health) assessments for the substances which will be used for the task (identified in section 1) must be stated here. Other (Specify): The reference numbers/titles of any other applicable documentation (i.e. documentation which includes information which will affect the safe completion of the task (identified in section 1) must be stated here.

-6- Competent Person

The name and signature of the competent person who is responsible for carrying out the task (identified in section 1) must be stated here. The date and time must also be noted. The Competent person is usually a supervisor or senior employee of the contractor carrying out the work

-7- Issuing Authority

The name and signature of the issuing authority must be stated here. The date and time must also be noted. The issuing authority is usually a senior employee of the controller of the premises.

-8- Cancellation
The Competent Person and Issuing Authority from sections 6 and 7 respectively must sign, date and enter the time here, when the task (identified in section 1 is completed. Notes 1) No other person should cancel the permit to work. 2) All times to be entered on the Permit to Work must refer to the 24hr clock. Additional Information When current, copies of the Permit to Work should be posted locally to the work area and a copy kept with the issuing authority. Expired Permit to Work forms require to be kept for record purposes.

-3- Task Classification

Indicate by ticking the appropriate box(es) the nature of the task (identified in section 1). If the work is not:- Cold Work, Hot Work, Electrical or Confined Space the tick Other (specify) and specify opposite the exactly the type of task. This permit must only be used for low voltage work. MONITORING RESULTS AND OR ISOLATIONS TO BE RECORDED ON THE REVERSE SIDE OF THIS PERMIT Monitoring results and or isolations must be recorded on the reverse side of the permit - to work Notes: 1) Monitoring results must include the following:-name and signature of the person carrying out the test, time, date, location and the result itself. 2) Isolation both electrical and mechanical specified and specific.

The Royal Bank of Scotland Mentor Services