Electrical Work Permit

Doc No. IMS_01_HSE_FOR_010

Revision No. 1.1
Izin ini berlaku untuk waktu yang ditentukan pada izin dan harus:
• Dikomunikasikan kepada kelompok kerja sebagai bagian dari pra-mulai; oleh Supervisor,
• Digunakan bersama dengan SWI yang relevan,
• Diverifikasi oleh Penerbit Izin,
• Disetujui oleh Pemberi Izin (Otorisasi),
• Memiliki salinan di area kerja, dengan izin asli, disimpan di kantor Penerbit Izin (HSE Office); dan
Memiliki detail diperbarui ke dalam Daftar Ijin untuk Bekerja.
Part A: Application
Date of Works: Work Supervisor Name:
Time of Works: Signature:
Work is to be conducted on: ☐High Voltage ☐Low Voltage
Location of Work

Detailed Scope of Work:

Hazards Identified:

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Status: Final Revision No. 1.1 Uncontrolled when printed 1
IMS_01_HSE_FOR_010
Electrical Work Permit
 Part B: Pre –conditions Assessment
Are the following required?
 Working at Heights Permit ☐Yes ☐No
 Confined Space Permit ☐Yes ☐No
 Isolation Permit ☐Yes ☐No
Are work activities compatible with other activities in the area? ☐Yes ☐No
A risk assessment has been conducted for this task (JHA)? ☐Yes ☐No
Have isolation procedures in accordance with the Vena Energy Isolation and
☐Yes ☐No
Tagging Procedure been implemented?
Is there positive isolation? ☐Yes ☐No
Is all safety equipment to be used maintained and checked prior to use? ☐Yes ☐No
Are personnel working alone? ☐Yes ☐No
Are supervisors monitoring the work? ☐Yes ☐No
Supervisor Name Supervisor Signature

Are additional pre-conditions required?

☐Yes ☐No
Specify:

Part C: Work Controls

All persons involved in the operation have been appropriately trained. ☐Yes ☐No
Has a minimum distance for high voltage work been confirmed? ☐Yes ☐No
Is high voltage access approved? ☐Yes ☐No
Is a spotter nominated? ☐Yes ☐No
Is the work area barricaded/cordoned off and warning signs displayed? ☐Yes ☐No
Has PPE been identified and made available? ☐Yes ☐No
Have all high voltage electrical apparatus been proven de-energised? ☐Yes ☐No
Has an emergency response plan has been identified and approved? ☐Yes ☐No
Part D: Permit Validity Period
(Note: Permits are only valid for the time frame specified below and shall not exceed 24 hours)
Permit Authoriser
Date Start Time End time
Signature

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Status: Final Revision No. 1.1 Uncontrolled when printed 2
IMS_01_HSE_FOR_010
Electrical Work Permit
 Part E: Spotter
I understand the requirements given for this job (given in this permit and attachments i.e. JHA) and will
comply with my duties as a spotter.
Spotters Name: Signature:
Spotters Name: Signature:
Part F: Permit User
I accept and confirm that I:
• Understand the nature of the work and associated risks,
• Meet the competency requirements to conduct the task safely; and
• Shall abide by all requirements identified within this permit.
Name Signature Date Time

Part G: Permit Authorisation

Permit Authoriser Signature Date

Details on this permit have been updated onto the Permit to Work Register: ☐Yes ☐ No
Part H: Permit Close Out
Confirm that:
 Lockouts and tags have been removed,
 The area is made safe and clean; and ☐Yes ☐ No
 The work area has been inspected to ensure that the energy system is in a
safe state before removing the isolation point.
Work Completed ☐ Work NOT Completed ☐
Permit User Name Signature Date Time

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Electrical Work Permit
Additional Comments:

Permit Number: _______________

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Status: Final Revision No. 1.1 Uncontrolled when printed 4
IMS_01_HSE_FOR_010
Electrical Work Permit