Fire Impairment Permit Submission

Fire Impairment Permit Submission
Promoting safety in your workplace

Fire Impairment is where fire protection equipment is taken out of service for a period of time. This situation requires tight on-site management along with a Fire Impairment Permit submission whenever part or all of the property's fire protection equipment and/or security systems are taken out of service.

Exclusion: A submission is not required where a contractor is carrying out standard weekly/monthly routine maintenance activities

Please select the circumstances that apply to this submission

	Yes	No
The impairment/isolation exceeds 12 hours in duration
The impairment/isolation occurs while no-one is present at the premises
The impairment/isolation impacts primary water supply (town mains and fire pumps)
The impairment/isolation impacts 25% or more of the building

Impairment details

	Yes	No	Reason for impairment/isolation
Alarm Panel
Alarm connection
Water supply
Fire pumps
Sprinklers
Hydrants
Smoke detectors
Thermal detectors
Other equipment or systems impacted

Where weekend work is involved in the impairment or isolation, select the days work is taking place

	Yes	No
Saturday
Sunday

Is this a recurring outage?

YesNo
If Yes, please provide details
Authorisation and Contractor details

In order to progress the submission, please provide the Authorised Workplace Manager's email (the person who approves the application) and the details of the preferred contractor to undertake the works
Authorised Workplace Manager Name

First NameLast Name
Authorised Workplace Manager Email
example@example.com
Authorised Workplace Manager Phone Number
Please enter a valid phone number.
Contractor Details

Nominate an approved contractor to undertake the impairment/isolation works. Where the work is undertaken internally, please include these details
Contractor Company Name
if applicable
Contractor Name*

First NameLast Name
Contractor Email*
example@example.com
Contractor Phone Number
Please enter a valid phone number.
Applicant signature

Clear
Applicant's date of submission*

DayMonthYear
Date
Insurance: The information provided in this submission will be shared with your insurance company in line with insurance policy requirements
Part 3 Contractor works

Please verify and complete all sections of the submission. Ensure the permit is displayed prominently at location.
Contractor Name confirmation*

First NameLast Name
Contractor Email confirmation*
example@example.com
Contractor Phone Number confirmation
Please enter a valid phone number.

Select the pre-cautions taken

	Yes	No	Comments
Fire detection systems are installed in the affected areas and will be fully operational across the duration of work
Sprinklers are installed in the affected areas and will be fully operational across the duration of work
Emergency response team notified
Fire Brigade notified
Hot work prohibited in affected areas (Not applicable where automatic sprinklers in the area are operational)
Smoking restricted in affected areas
Ongoing patrol of affected areas is arranged and in place
Fire hoses laid out and extra portable fire extinguishers provided within the affected area/s
Alternate water supply connected (e.g.: Sprinkler riser connected to hydrant system etc.)
Spare sprinkler heads are available
Other areas (please provide details in the comments area)

Select applicable end of day impairment/isolation restoration procedures*

	Yes	No	Comments
All affected water control valves confirmed to the fully opened
All affected water control valves secured in the open state using sturdy locks and chains
All associated alarm solutions on fire panel cleared
Others (please provide details)

Contractor verification of works - please provide comments to be shared with the Authorised Workplace Manager where relevant*

	Yes	No	Comments
The work has been completed to the best of my ability and knowledge
All work equipment, materials and waste has been removed from the site
Barricade, fencing and warning signage has been removed
All plant and equipment has been readiness tested and the areas are fit for use
Fire protection/detection systems have been fully reinstated and the job is restored to safety
I am not aware fo any further action required

Workplace Safety

	Yes	No	Comments
Were there any workplace incidents or injuries that occurred while you were on the job?

If Yes, please provide details of the workplace incident or injury
Contractor Signature

Clear
Part 4 Authorised Workplace Manager

Closure confirmation
Are you satisfied with the quality of the work performed by the contractor? (1 Very Unsatisfied to 5 Highly satisfied)

Very unsatisfied Unsatisfied Neutral Satisfied Highly satisfied

Verification and closure of works*

	Yes	No	Comments
The Fire Impairment or isolation has been completed by the contractor
The permit has been returned to a nominated workplace person
A workplace inspection has been undertaken by myself or a qualified nominated person on site
I am satisfied the workplace systems are restored safely to resume work and requires no further action

Confirmation Authorised Workplace Manager Name*

First NameLast Name
Authorised Workplace Manager Position Title
Authorised Workplace Manager's Phone Number*
Please enter a valid phone number.
Authorised Workplace Manager Signature - Fire Impairment completion*

Clear
Date*

DayMonthYear
Date
Insurance: The information provided in this submission will be shared with your insurance company in line with insurance policy requirements
Should be Empty:

Part 1 Property and Site Contact details