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Contractor Permit to Work

Contractor company name:

Name of person/s performing
the work:
Location of the work:
Work Start Date: Start Time:
Work Completion Date: Finish Time:

Scope of Work to be

Name of person at {YOUR

COMPANY} responsible for
supervising contractor:

Tasks to be performed include, or could include): (Select all that apply)

Work in high traffic areas Abrasive blasting Window cleaning
Hot work (including Use of hazardous Work on or near electrical
welding, cutting and grinding chemicals (paints, fuels, equipment
etc) solvents etc)
Work in areas near Work on Asbestos Use of mobile plant (eg.
members of the public Containing Materials forklift, crane, vehicle)
Demolition Erecting scaffolding Confined space entry
Working at heights >2m (eg. roof work, ladders, cherry pickers, Excavation or trenching
scissor lift etc) Using power tools
Other tasks (specify):

Risk Assessment:
The hazards involved in this work include:

How likely is it that an incident would result from this work?

Unlikely Possible Extremely Likely
If an incident did occur, what is the likely severity?
Minor injury or damage Serious injury or moderate Death or major
damage damage
Contractors Declaration: Yes No
Have you provided a Safe Work Method Statement (or other safe work procedure, JSA
etc) for the work to be performed, which details controls measures for the hazards
listed above?
Are you competent to perform the work?
Have you received relevant training in these tasks?
Do you hold any relevant licenses for certifications for these tasks?
Have you completed the {YOUR COMPANY NAME} Insurance Assessment?

I ________________________________________ of ________________________________________
(print full name) (print Company name)

a) understand my duties under Queensland work health and safety laws (including Codes of Practice and
Australian Standards that are applicable to the work being undertaken) and to the circumstances in
which the work will be conducted

b) hold current certification, qualifications and licenses that are required by legislation required for this

c) have completed the {YOUR COMPANY NAME} site induction

d) will cease working, make safe the workplace and contact the {YOUR COMPANY NAME} site contact if I
become aware of danger to myself or others during the period of the work

e) have a current Workers Compensation and Rehabilitation Insurance Policy in place

f) agree to comply with all the site safety requirements and reasonable directions given by {YOUR

Signature: Date:

{YOUR COMPANY NAME} Permit to Work Authorisation:

This work is authorised to proceed from:
Permit Start Date: Start Time:

Permit Completion Date: Finish Time:

Name: Signature:

To be signed off by {YOUR COMPANY NAME} upon completion of the works:

I have inspected the work and the work area, and believe to the best of my knowledge, that the work has
been completed safely and the work area left in a safe state.

Name: Signature:

Date: Time: