Infectious Disease Control Plan - COVID-19 - Flipbook - Page 37
PERMIT TO WORK (Complete all “Gray Fields”)
DATE:
TIMES:
LOCATION:
PERMIT #:
PROJECT:
GENERAL PROJECT INFORMATION
Teamwrkx
Supervisor:
Contact Number:
Notified?
☐ Yes ☐ No
Description of Expected Environmental Noise:
Teamwrkx Supervisor:
Contact Number:
CONTRACTOR/VENDOR:
Office Number:
Responsible Person:
Contact Number:
Vendor Signature:
Facilities Engineer OnCall:
Contact Number:
☐ Yes ☐ No
Has Security been notified?
Notified?
Will Contractor be issued T badges?
☐ Yes ☐ No
☐ Yes ☐ No
WORK ACTIVITIES & IMPACTS (Check All That Apply – Required Forms ~ See Reverse Side)
Does the activity impact a Validated Space?
☐ Yes ☐ No
Are there any safety implications resulting from these shutdowns?
Validated Equipment?
☐ Yes ☐ No
☐ Yes ☐ No
Has EH&S been notified?
Who?
☐ Yes ☐ No
☐ Hot Work ☐ Confined Space
☐ Energy Control or LOTO ☐ Energized Electrical Work ☐ Elevated Work
☐ Excavation
Utilities and/or Services to be Shut Down:
☐ None
☐ Fire Sprinklers
☐Fire Alarm
☐ Compressed Air
☐ Vacuum
☐ RTO
☐ Domestic Water
☐ Electrical
☐ Nitrogen
☐ Air Conditioning
☐ Other
Has GIS been notified?
☐ D.I. Water
☐ Data
☐ Yes ☐ No
Will Manufacturing equipment be shut down?
Which items?
☐ Yes ☐ No
Has Manufacturing Work Request Form been circulated and signed? ☐ Yes ☐ No ☐ N/A
Person Issuing Permit to Work:
Work Approved (Signature Required):
Contractor understands that none of the above noted items may not be shut down or interrupted without prior written permission?
(Initial)
WORK ACTIVITY CONTROL PLAN
WORK DAY COMPLETION
Has work been reviewed by Project Manager?
Is the area left clean and safe?
Have affected/impacted utilities been re-activated?
Is there remaining work to be completed?
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
Describe:
When:
Sign Off:
Date:
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