Introduction to Health and Safety at Work

Principles of control
99
 
Appendix 6.1 Fire notice

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Introduction to Health and Safety at Work
100
 
Appendix 6.2 Job safety analysis form
JOB SAFETY ANALYSIS
Job Date
Department Carried 
out 
by
Description of job
Legal requirements and guidance
Task steps 
Hazards 
Consequence 
Severity 
Risk C 
⫻
S 
Controls
Safe system of work
Job Instruction
Training requirements
Review date

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Principles of control
101
 
Appendix 6.3 Essential elements of a permit-to-work form
2.
Should have any reference to other
1 Permit Title 
2 Permit Number
relevant permits or isolation certifi cates.
3 Job Title
4 Plant identifi cation
5.
Description of work to be done
5 Description of Work
and its limitations.
6.
Hazard identifi cation including residual
6 Hazard Identifi cation
hazards and hazards introduced by the work.
7.
Precautions necessary – person(s) who
7 Precautions necessary 
7 Signatures
carry out precautions, e.g. isolations, should 
sign that precautions have been taken.
.......................................... 
....................................
.......................................... 
....................................
.......................................... 
....................................
8. Protective equipment needed for the task. 
8 Protective Equipment
9.
Authorization signature confi rming
9 Authorization
that isolations have been made and 
precautions taken, except where these 
can only be taken during the work. Date 
and time duration of permit.
10.
Acceptance signature confi rming
10 Acceptance
understanding of work to be done, hazards 
involved and precautions required. Also 
confi rming permit information has been 
explained to all workers involved.
11.
Extension/Shift handover signature
11 Extension/Shift handover
confi rming checks have been made that 
plant remains safe to be worked on, and 
new acceptance/workers made fully 
aware of hazards/precautions. New time 
expiry given.
12.
Hand back signed by acceptor certifying
12 Hand back
work completed. Signed by issuer certifying 
work completed and plant ready for testing 
and re-commissioning.
13.
Cancellation certifying work tested and
13 Cancellation
plant satisfactorily re-commissioned.
Source HSE

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