SANCTION TO TEST

PLANT…………………… SANCTION NO..................

SECTION 1
The following apparatus IS NOT ISOLATED from the source of energy. The
apparatus is still in a workable condition and hence POTENTIALLY
DANGEROUS.

SECTION 2
This sanction to test applies to the following apparatus only
machine/area..................................................
date.............................................................. .
time...............................................................

SECTION 3A CERTIFICATE OF APPOINTMENT

THIS CERTIFICATE IS VALID ONLY FOR THE SHIFT IN WHICH IT IS
ISSUED OR THE COMPLETION OF THE OBSERVATION/ TEST
(WHICHEVER IS EARLIER)
A CERTIFICATE OF APPOINTMENT MAY ONLY RELATE TO ONE
PERSON.
This certificate appoints....................................( name) to enter a guarded area or
remove guards without isolating the source of energy from the apparatus( for the
purposes of observation and testing only).

SECTION 3B
Signed....................................(Issuing Authority)Date........................Time............

Signed....................................( Authorisation ) Date........................Time............

THE FOLLOWING PRECAUTIONS MUST BE ADHERED TO

SECTION 4 SPECIAL SAFETY INSTRUCTIONS / PPE/RISK
ASSESSMENT
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................
.....................................................................................................................................

SECTION 5 ( To be completed by the person appointed in section 3A)

I hereby declare that
1 The task designated is complete / incomplete
2 All guards have / have not been replaced
3 The machine has / has not been left in a safe working condition.

Signed..........................................................Date........................Time..............

SECTION 6 CANCELLATION
I hereby declare that certificate is now cancelled.

Signed....................................(Issuing Authority)Date........................Time............
Signed....................................(Authorisation) Date........................Time............