| No | Item | Yes | No | Comments |
|---|---|---|---|---|
| 1 | Permit to Work is completed and authorized | |||
| 2 | Atmospheric testing conducted and results acceptable | |||
| 3 | Emergency and rescue plan discussed | |||
| 4 | Personal protective equipment (PPE) available and worn | |||
| 5 | Isolation of services (electrical, gas, etc.) completed | |||
| 6 | Entry and exit points identified and accessible | |||
| 7 | Communication system established | |||
| 8 | Standby person assigned and briefed | |||
| 9 | All tools and equipment checked and suitable | |||
| 10 | Signage and barricades in place |
| No | Name | Position | Signature | Date |
|---|---|---|---|---|
| 1 | ||||
| 2 | ||||
| 3 | ||||
| 4 |