ALC-HSEF-017 Date: 05/10/2021 REV NO: 00 Page 1 of 3
Allied Contracting L.L.C
WORK ENTRY PERMIT
1. Permit Application
Permit Name: Permit No :
Permit Applicant
applicant
Work Area: Drawing attached : Yes/No
Date: Permit Validity: (Time) No of persons working:
From: To:
Job to be done (Job description can
be detailed on a separate sheet if
required):
2. Engineering and Administrative verification (Please “√” the relevant boxes)
Integrity Yes No
1 Is design and calculation for the formwork available?
Is the formwork structure erected according to design
2
and drawing?
Is the formwork structure designed with a minimum
3
safety factor of 2?
Is there approved agency issued certificate stating that
4
the formwork is safe for use?
Supports and Shores
Are horizontal/diagonal bracings provided in
5
both longitudinal & transverse directions?
Are the propping properly seated top and bottom to
6
prevent displacement?
Are the shores of the formwork structure of adequate
7
size and spacing?
Supervision
8 Has a Formwork inspected by structural Engineer and CM
Are inspections done by consultant after the completion
9
of the formwork and recorded into a register?
Risk Management & Work Planning
Has risk assessment (RA) been conducted for the
12
formwork operation & communicated to the staff?
Is a Lifting Plan established and implemented for
13
lifting operations involved?
ALC-HSEF-017 Date: 05/10/2021 REV NO: 00 Page 2 of 3
Are visual checks conducted to ensure that anchorage
17
for the formwork is fully engaged?
Have all persons using the fall arrest systems
18 undergone training to understand the safe and correct
use of the system?
19 Does all the persons aware about (Red and Green flag
System)
3. Hazards and Precautions (Please “√” the relevant boxes)
Hazards Precautions/Control Measures
Bodily Injury (Head, Hand, leg Helmet, Hand gloves, Safety shoes, Coverall
etc)
Eye, Ear, face injury Safety goggles, Ear muff/plug, Full face visor,
Electrical fire Cables in good condition, no joints and open wires
Work at Height Scaffold inspected & tagged. Toe boards and
guard rails
Fall of people through openings Edge protection or similar alternative must be provided
Permit Applicant
at all openings and edges. Use Personal fall arrest
system.
Safe Access Adequate access should be provided.
Falling objects Stack materials away from
edge/clean/remove/cover top
Falling on to the people Barricade the area, provide watch man
Material falling through the shaft Cover up by wooden planks on top and bottom
sides.
Dust, vapor, fumes Sufficient ventilation, exhaust.
Material damage from falling Clear the materials from the work area.
objects
High risk activity Close supervision
Manual Lifting Use of sufficient man power
Others: TBT to be given by the work in charge and submitted to
safety dept.
3. Safety Commitment:
I, being the in charge of the above work understand the hazards and taken all above
Applica
Permit
precautions and ensuring full adherence to the same. I also undertake to continuously
nt
adhere to the intermittent precautions, where applicable, during the course of job.
Name: Signature:
4. Area clearance: (By SE/PE/SM)
The work is safe to carry out the hot work and handed over to the permit applicant for the above work.
Name: Signature:
5. Permit approval by (HSE Officer)
Permitted/Not permitted. Comments:
(Note : Permit will be invalid if any safety precautions/control measures are not in place)
Name: Signature:
Permit close out request (By the permit applicant)
I have inspected the work site after the completion of work and I certify that the area is cleaned and
brought to the normal condition.
Name : Signature
ALC-HSEF-017 Date: 05/10/2021 REV NO: 00 Page 3 of 3
