Safe Work Permit

Safe Work Permit

24-Hour Emergency Number: 1-844-547-2666
Date

MonthDayYear
Date
Permit Issuer
Permit Issuer Email Address
example@example.com
Signature
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Contact
Alternate Contact Email
example@example.com
Alternate Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Permit Valid from:
Permit Valid to:
Date of Permit Expiry:

MonthDayYear
Date
Contracting Company
Location(s)
Type of Operation
If you chose Other above, please specify

Indicate Type of Work (attach all applicable permits):
Purpose/Description of Work:

Potential Site-Specific Hazard #1 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Required Control #1 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Potential Site-Specific Hazard #2 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Required Control #2 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Potential Site-Specific Hazard #3 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Required Control #3 (choose from the dropdown menus)
If you chose “OTHER” above, explain:
Additional Comments

AGREEMENT: I understand and agree that no work is permitted other than that specified on this permit. I have checked both the permit and the job and I understand the nature and extent of the work and the precautions to be followed in completing the work. I also agree that any other employees or sub-contractors who will, or may work on this job shall have a complete understanding of the conditions of this permit and will also work under the conditions of this permit.
Permit Receiver #1

First NameLast Name
Permit Receiver Email Address
example@example.com
Signature
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Sign On #1

First NameLast Name
Additional Sign On #1 Email Address
example@example.com
Signature
Additional Sign On #2

First NameLast Name
Additional Sign On #2 Email Address
example@example.com
Signature
Additional Sign On

First NameLast Name
Signature
Additional Sign On

First NameLast Name
Signature
Additional Sign On

First NameLast Name
Signature
Ensure any additional personnel working under this permit sign off on vendor Pre-Job Hazard Assessment/Tailgate Meeting – attach documentation
Is the job complete?
If you chose “No” above, please explain
Job Completion Date and Time
Signature
Should be Empty:

Rows	Yes	No	N/A	Comments
Have the Contractor and the workers completed Entrada’s HSE Orientation (if applicable)? (Site-Specific)
Do all workers have current required safety training (e.g. WHMIS, TDG, H2S, First Aid)?
Is work being conducted on a Sour Location?
Has a review of emergency procedures been conducted? (Muster Point Identified)
Has a pre-job safety meeting been held? Attach pre-job hazard assessment / tailgate meeting documentation
Have all applicable personnel signed off on pre-job safety documentation?
Do Safe Operating Procedures (SOP) exist for the job and been discussed with the vendor?
Have Working Alone considerations been taken into account?
Have wind, atmospheric, and work area conditions (e.g. temperature, snow, ice, poor lighting been considered throughout the job so that work can be done safely?
Is a fall arrest plan and training in place? Required after 3m - attach Fall Protection Plan
Are all applicable diesel trucks in the area equipped with a positive air shut off?
Have all overhead power lines, or other hazards been identified and marked? Proper Signage? (Overhead lines – minimum safe distance of 7 meters must be maintained. If work is within 7 meters, mandatory orientation via power company required)
Is there ground disturbance of 30cm or greater and if so, have all underground utilities, pipelines, or other hazards been identified and staked? If yes, Ground Disturbance Permit required.
Have all WHMIS and TDG requirements been met? Attach SDS sheets as required.
Has all applicable equipment been Locked Out/Tagged Out and all potential energy sources de-energized? Attach LO/TO form

Safe Work Permit

Ensure any additional personnel working under this permit sign off on vendor Pre-Job Hazard Assessment/Tailgate Meeting – attach documentation