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RISK WORK PERMIT REQUEST FORM
Country:
*
Location:
*
Area:
*
Responsible of the area:
*
Start date & time:
*
Choose Date
April 2026
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Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
End date & time:
*
Choose Date
April 2026
Sun
Mon
Tue
Wed
Thu
Fri
Sat
14
29
30
31
1
2
3
4
15
5
6
7
8
9
10
11
16
12
13
14
15
16
17
18
17
19
20
21
22
23
24
25
18
26
27
28
29
30
1
2
19
3
4
5
6
7
8
9
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Requester name:
*
Email:
*
Company:
*
Contractor Name
Email
Specific equipment:
*
Describe work to be performed:
*
Risk Description
High-risk jobs identified:
*
Excavation
Electrical Work
Hight Voltage Work
Hoist or Scaffolding Works
Other
Characteristics of the work environment:
*
Exposed electrical service
Exposure to high / low temperatures
Exposure to rain
Exposure with insects (bees)
Humidity
Slippery floor
Excessive noise
Traffic of People / Vehicles
Other
Observed Hazards:
*
Chemicals
Flammable products
Noise
Vapors or Gases
State of electrical installations
Filing
Biological
Electrical Discharges
Temperature
Ergonomic
Moving vehicles
Mandatory personal protective equipment:
*
Safety harness
Grinding mask
Welding helmet
Industrial helmet
Reflective vest
Self contained team
Leather gabacha
Anti cut gloves
Leather gloves
Chemical Handling Gloves
Protection glasses
Full face mask
Mandatory minimum requirements for the start and execution of works.:
*
Isolate and delimit work area
Scaffold (s) in good condition
Power lock
Drain pipes or tanks
Request Permission to use auxiliary plant services (electricity, air, water, steam, and equipment in general)
Explosion Proof Equipment
Stairs in good condition
Power cords in good condition
Fire extinguisher on hand minimum of 20 pounds
Label machine under maintenance
Measure Explosive%
Measure% oxygen
Protect grates and trants
Remove flammable material
Vigilant
Ventilate the area
Communication Equipment (radios)
Review of tools and equipment used:
*
Scaffold
Basin
Basin hand cart
Gas cylinder
Oxyfuel equipment with non-return valve
Air compressor
Stairs
Excavator
Milling machine
Pressure gauges
Manual tools
Hose
Welding machine
Air gun
Paint gun
Lifting platform
Polisher
Rotary hammer
Circular saw
Blowtorch
Drill
TorTurnstileno
Other
Requirements to be fulfilled at the end of the work activity or maintenance task.:
*
Notify to reinstall electric power
Order and cleanliness
Communicate to the area manager
Report accidents and incidents
Remove equipment and / or tools
Remove electrical installations
Communicate to the person in charge of Industrial Safety
Other
Observations:
*
Recommendations:
*
Verification of Work at Heights
(Optional)
Select if work will be carried out at heights
Description of the work to be done / Activity at Height:
*
Potential Risks
Potential Risks
Trabajo en Techos:
*
Yes
No
N/A
Flow Annex 19 - Requirements for roof work are taken care of:
*
Yes
No
N/A
Skylight without cover or protected:
*
Yes
No
N/A
Inappropriate access to get on and off:
*
Yes
No
N/A
Unmarked or uninsulated roof openings:
*
Yes
No
N/A
Unprotected, unmarked or exposed ventilation spaces:
*
Yes
No
N/A
Exposed pipes without adequate marking or protection:
*
Yes
No
N/A
Falling objects from height:
*
Yes
No
N/A
Electric cables above the head without protection:
*
Yes
No
N/A
Structures above the head exposed, without marking or protection:
*
Yes
No
N/A
Exposure to chemicals, fumes, or dusts:
*
Yes
No
N/A
Suitable climatic conditions:
*
Yes
No
N/A
Access method and prevention measures
Access method and prevention measures
Preliminary Risk Analysis suitable for the activities; (attach to work permit):
*
Yes
No
N/A
Existing scaffold assembly project / scheme:
*
Yes
No
N/A
Adequate moving stairs (identified and marked according to the inventory):
*
Yes
No
N/A
Fixed ladders inspected and adequate:
*
Yes
No
N/A
Protections of the eaves in the appropriate height and with signaling of a minimum distance of 2m:
*
Yes
No
N/A
Appropriate elevator platforms with a completed checklist:
*
Yes
No
N/A
Lifting baskets for trucks and cranes with proper documentation and reports:
*
Yes
No
N/A
Suspended chairs in accordance with local legislation:
*
Yes
No
N/A
Appropriate bodyguards:
*
Yes
No
N/A
Appropriate skirting:
*
Yes
No
N/A
Protective nets installed and adequate:
*
Yes
No
N/A
Metal plate or wood available:
*
Yes
No
N/A
Appropriate and certified seat belt:
*
Yes
No
N/A
Proper safety boots:
*
Yes
No
N/A
Signaling and insulation plates installed properly:
*
Yes
No
N/A
Anchor points existing and installed according to method statement:
*
Yes
No
N/A
Other Access Methods and Prevention Measures:
(Optional)
Stairs / bleachers / stair access
Stairs / bleachers / stair access
In good working condition without dirt from oils, greases, inks, slippery materials:
*
Yes
No
N/A
Safe in relation or support of the base and the toe, anti-slip installed on the ladder:
*
Yes
No
N/A
The ladder is at a safe distance from the electrical networks:
*
Yes
No
N/A
Any equipment / tool is lifted attached to a rope and hoisted separately:
*
Yes
No
N/A
Stairs next to pedestrian / vehicle crossings are signposted and protected:
*
Yes
No
N/A
Opening ladders are properly locked before use:
*
Yes
No
N/A
Extendable ladders have adequate couplings and transfer:
*
Yes
No
N/A
The ladder exceeds 1 meter above the upper support point:
*
Yes
No
N/A
Elevating Platform
Elevating Platform
Equipment used is inspected and approved by a competent person:
*
Yes
No
N/A
The people who will carry out the activities are adequately trained and qualified:
*
Yes
No
N/A
The transit of people and pedestrians from the place of the execution are signposted:
*
Yes
No
N/A
Fall protection system is available:
*
Yes
No
N/A
Safety Harness and shock absorbing lanyards were inspected:
*
Yes
No
N/A
Personal protective equipment is adequate:
*
Yes
No
N/A
There is a safe distance from electrical networks:
*
Yes
No
N/A
Safe distance of 5m against impacts in proper air movement:
*
Yes
No
N/A
Equipment and Tools held securely to avoid falls:
*
Yes
No
N/A
Scaffolding
Scaffolding
The assembly meets a safe distance from the electrical network:
*
Yes
No
N/A
Access is made by ladder fixed to the scaffold:
*
Yes
No
N/A
The plates / boards are 2.5 centimeters thick and maximum spaces of 2 meters:
*
Yes
No
N/A
The plates / boards are fixed:
*
Yes
No
N/A
The wood used in the board is of good quality, dry, without cracks:
*
Yes
No
N/A
The floor of the plates / boards, covers the entire length of the scaffold and does not leave gaps between plates / boards:
*
Yes
No
N/A
Level scaffold with shoe for transmission of the load to the ground or when equipped with wheels, they are in good condition and locked before the access of the performers:
*
Yes
No
N/A
Scaffold anchored to the fixed structure at every 3m and contraventeda according to the assembly diagram:
*
Yes
No
N/A
Scaffold not moved with people on top:
*
Yes
No
N/A
Equipment, materials and tools are not loose on the scaffold:
*
Yes
No
N/A
The lifting of materials is carried out by rope and pulley:
*
Yes
No
N/A
Pieces are not thrown in free fall:
*
Yes
No
N/A
The activities are not carried out in rain or strong wind:
*
Yes
No
N/A
The performers of the task have a health certificate and blood pressure was verified.:
*
Yes
No
N/A
Services must always be performed by a minimum of two people:
*
Yes
No
N/A
Areas with traffic of people are isolated due to the risk of falling objects:
*
Yes
No
N/A
Scaffolding (Suspension mounting)
Scaffolding (Suspension mounting)
Suspension cables are armed according to the project:
*
Yes
No
N/A
The scaffolds are supported by beams in balance, according to the project:
*
Yes
No
N/A
Suspension steel cables are protected against friction when they come into contact with the edges:
*
Yes
No
N/A
Suspension cables do not have oxidation, wire breakage, or permanent deformation:
*
Yes
No
N/A
Support cables are unremoved:
*
Yes
No
N/A
The suspended chair has approval certification:
*
Yes
No
N/A
Precautionary Measures
Precautionary Measures
Signaling, isolation and safety barriers are adequate:
*
Yes
No
N/A
Special measures:
(Optional)
Individual and collective protection equipment
Individual and collective protection equipment
Lifelines, adequate structure with anchor points and adequate fall protection system in accordance with the method statement:
*
Yes
No
N/A
Dual lanyard harness with shock absorber:
*
Yes
No
N/A
Impact Protection Glasses:
*
Yes
No
N/A
Leather gloves:
*
Yes
No
N/A
Helmet with chinstrap:
*
Yes
No
N/A
Security boots:
*
Yes
No
N/A
Other Personal and Collective Protection Equipment:
(Optional)
Handling / Approval of authorized personnel
Handling / Approval of authorized personnel
The requirements for working at height are fully met when performing the activities described:
*
Yes
No
N/A
All the requirements of this work permit are fully met:
*
Yes
No
N/A
All persons involved in the work were informed:
*
Yes
No
N/A
People performing the activities
People performing the activities
(Optional)
Verification of Confined Spaces
(Optional)
Select whether work in confined spaces will be performed:
Description of the work to be done:
*
Procedures to be completed prior to entry
Procedures to be completed prior to entry
Initial Atmosphere Test:
*
Testing After Ventilation and Isolation:
*
Measure Oxygen %:
*
Measure Explosivity%:
*
Measure% Flammability:
*
Measure% Toxic gases and vapors:
*
Measure% Dust, fumes and toxic snow:
*
Potential Risks (Please identify those that apply)
Potential Risks (Please identify those that apply)
YES The oxygen concentration is less than 19.5% or greater than 22% oxygen by volume:
*
Yes
No
N/A
If there is presence of hazardous / flammable / explosive gases, smoke, vapor or dust:
*
Yes
No
N/A
If there is a possibility that the confined space will be suddenly filled by liquids or solids:
*
Yes
No
N/A
Risks evaluation
Risks evaluation
Preliminary Risk Analysis suitable for the activities; (attach to work permit):
*
Yes
No
N/A
All lines to the confined space (containing inert, toxic, flammable, corrosive materials, etc.) were closed or disconnected and separated before entering (adequate isolation):
*
Yes
No
N/A
Welding gas cylinders are stored and properly secured outside the confined space:
*
Yes
No
N/A
No need for supplemental ventilation:
*
Yes
No
N/A
Automatic fire suppression systems disabled:
*
Yes
No
N/A
Risk assessment for accidental starting of equipment or its parts - Impellers, agitators, or other moving parts and equipment, within confined spaces, have been shut down, are blocked and tagged:
*
Yes
No
N/A
Risk assessment for the presence of hazardous or hazardous waste - The confined space is completely clean:
*
Yes
No
N/A
Electrocution risk assessment - Insulation is adequate:
*
Yes
No
N/A
Extra high voltage equipment will be needed:
*
Yes
No
N/A
There is a risk of sudden decrease or increase in temperature:
*
Yes
No
N/A
There is adequate lighting:
*
Yes
No
N/A
There is a risk of falling:
*
Yes
No
N/A
Communication techniques or agreements were established prior to admission:
*
Yes
No
N/A
It was verified whether the entrance to the confined space is large enough to allow easy entry and exit and to provide emergency assistance.:
*
Yes
No
N/A
Precautionary measures
Precautionary measures
Signaling, isolation and safety barriers are adequate:
*
Yes
No
N/A
Assessment of work materials and tools - Tools do not generate sparks, lighting is explosion proof in flammable or potentially explosive atmospheres:
*
Yes
No
N/A
The equipment used is low voltage:
*
Yes
No
N/A
All workers who will carry out the work are adequately informed and trained regarding the tasks to be carried out, the risks of confined spaces and the precautions in case of emergency:
*
Yes
No
N/A
The premises must be drained:
*
Yes
No
N/A
The premises must be washed:
*
Yes
No
N/A
The premises must be purged:
*
Yes
No
N/A
Inert gas must be injected:
*
Yes
No
N/A
Special measures:
(Optional)
Individual and collective protection equipment
Individual and collective protection equipment
Lifelines, adequate structure with anchor points and adequate fall protection system in accordance with the method statement:
*
Yes
No
N/A
Dual lanyard harness with shock absorber:
*
Yes
No
N/A
Impact Protection Glasses:
*
Yes
No
N/A
Leather gloves:
*
Yes
No
N/A
Helmet with chinstrap:
*
Yes
No
N/A
Security boots:
*
Yes
No
N/A
PVC boot:
*
Yes
No
N/A
Respiratory protection:
*
Yes
No
N/A
Filter mask:
*
Yes
No
N/A
Sanitation Suit:
*
Yes
No
N/A
Tyvek Suit:
*
Yes
No
N/A
Autonomous set:
*
Yes
No
N/A
Commanded air set:
*
Yes
No
N/A
Other Personal and Collective Protection Equipment:
(Optional)
Rescue assessment in case of emergency
Rescue assessment in case of emergency
There is an appropriately trained and equipped watchdog to carry out the emergency:
*
Yes
No
N/A
The rescue harness is ready:
*
Yes
No
N/A
Emergency rescue breathing apparatus is ready:
*
Yes
No
N/A
There is an alert system:
*
Yes
No
N/A
People performing the activities
People performing the activities
(Optional)
Hot Work Verification
(Optional)
Select whether hot work will be performed:
Description of the work to be done:
*
Hot work type
Hot work type
Cut, wear and weld:
*
Yes
No
Shredding Chemical Pipes:
*
Yes
No
All activities involve welding:
*
Yes
No
Welding Type:
*
Coupling / installation of pipes and fittings:
*
Yes
No
What Other Activities Involve Open Flame:
*
What other activities produce flames or sparks:
*
Check List Of Requirements And Care
Check List Of Requirements And Care
Hoses / Hydrants, in operation, can be used while the work is done:
*
Yes
No
N/A
Sprinklers / Sprinklers available, if applicable:
*
Yes
No
N/A
Fire alarms (smoke detector, or heat detector) are activated during activity.:
*
Yes
No
N/A
The necessary temporary security informations were made? (SESMT / Firefighters / Insurance Company):
*
Yes
No
N/A
Hot work equipment (welding equipment or flame or spark producers) are in good condition and adequate, torches have short flow valve:
*
Yes
No
N/A
Emergency brigade was informed:
*
Yes
No
N/A
Work is limited to the area or equipment specified in this document:
*
Yes
No
N/A
10m distance safety requirement
10m distance safety requirement
All combustible materials were removed or protected with metal blankets or plates:
*
Yes
No
N/A
All openings in the walls, floor and gutters were adequately closed or covered:
*
Yes
No
N/A
The floor is clean free of dust, liquids, grease or any other flammable product:
*
Yes
No
N/A
Flammable material floors were moistened, covered with sand or fire-resistant blankets:
*
Yes
No
N/A
Safety requirements for activities in explosive atmospheres
Safety requirements for activities in explosive atmospheres
All combustible materials, vapors, gases, liquids, deposits derived from oil were removed.:
*
Yes
No
N/A
Elements that make up an explosive atmosphere were removed (dust, gases, vapors):
*
Yes
No
N/A
The area is well ventilated (Natural or forced):
*
Yes
No
N/A
Tanks or equipment in closed rooms that contain combustible products were drained, emptied and cleaned, or are with continuous forced ventilation:
*
Yes
No
N/A
Switches and electrical installations are adequate, locked and identified:
*
Yes
No
N/A
The absence of vapors / gases / dust was verified by a suitable gas meter.:
*
Yes
No
N/A
Requirements for wall and ceiling work
Requirements for wall and ceiling work
The activity is being carried out in a safe place free of combustible material:
*
Yes
No
N/A
Electrical parts are insulated in good condition (metal walls in good condition, no loose or exposed insulation parts):
*
Yes
No
N/A
Fuels on the other side of the walls were removed:
*
Yes
No
N/A
There is no heat conduction for other areas:
*
Yes
No
N/A
Organization: emergency brigade / hot work area monitoring
Organization: emergency brigade / hot work area monitoring
Performers will be equipped with appropriate fire extinguishers (chemical powder or CO2):
*
Yes
No
N/A
Area brigade, fire extinguishers, alarms in response to the occurrence of fire:
*
Yes
No
N/A
Area will be accompanied by brigadista for a minimum period of 1 hour after the work is finished:
*
Yes
No
N/A
Necessary the division of the brigadistas in the sectors:
*
Yes
No
N/A
Sectors:
*
Brigade member:
(Optional)
Organizational: Other preventive measures to be taken
Organizational: Other preventive measures to be taken
All the requirements corresponding to Confined Spaces are observed:
*
Yes
No
N/A
Specific requirements for confined spaces are necessary; (complete specific form):
*
Yes
No
N/A
Ventilation is necessary to remove fumes from the area:
*
Yes
No
N/A
Personal Protective Equipment is available and being used:
*
Yes
No
N/A
Energy Lock (LOTO)
Energy Lock (LOTO)
Executed according to PTER General procedure:
*
Yes
No
N/A
There is a requirement for additional power lockout:
*
Yes
No
N/A
Specify procedure:
(Optional)
Responsibility in emergency
Responsibility in emergency
Evacuation route is known to all performers:
*
Yes
No
N/A
Emergency telephone / extension is known to all performers:
*
Yes
No
N/A
The Emergency Action Plan is well understood by all:
*
Yes
No
N/A
Emergency Response Communication Systems are working / List of existing emergency procedures and is available for use:
*
Yes
No
N/A
If there are Others Specify:
(Optional)
People performing the activities
People performing the activities
(Optional)
Submit
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