PERMIT TO WORK DOCUMENT CHECKLIST

Date
Work Activities
Person In Charge
Sub-Contractor

NO ITEM YES NO NA
1 COPY OF HIRARC:
2 COPY OF SAFE WORK INSTRUCTION / PROCEDURE:
3 PRE TASK TALK / PRE TASK BRIEFING RECORDS
4 RELATED INSPECTION FORM
1.
2.
3.
5 EMERGENCY CONTACT NUMBER

Prepared By: Verified By:

Name: Name:
Position: Position:
Company: Company: