Contractor Work Permit
v4.0
Instructions
Contractors will not be permitted to commence work on site until:
This Work Permit is reviewed and approved by an authorized Sodexo Representative (see page 2)
Each Worker has been orientated to the worksite and a valid Site Contractor Safety Orientation Form has been signed as evidence wtihin one calendar year of the current date.
A Sodexo purchase order has been issued for the work.
Instructions for completing this form:
Complete each section in its entirety. Any questions regarding all topics, definitions and controls shall be directed to your Sodexo Contact.
Empower each person to understand that they have the right and responsibility to stop any unsafe work activity without consequence.
Ensure that incident reports are available to everyone to document any behaviours or conditions relevator to the task at hand.
Immediately report any injury or near miss to your Sodexo Contact.
General Information
Work Location:
Building Service Interruptions
Company Name:
Work may result in an interruption to the following services:
Date:
Time/Duration:
 Electrical Interruption
 Telecommunications
Supervisor Name:
 Natural Gas Interruption
 Fire Protection Systems
Supervisor Telephone No.:
 Domestic Water
 Other: _____________________
Brief Description of Work to be Completed
Workers Present on Site
All workers present on site must sign below to indicate that a Job Hazard Analysis has been completed, (see below and page 2 of this form) and its objectives and
plan are clearly stated and understood by all workers.
Name
Contact Telephone No.
Trade Certificate No.
Signature
Sodexo Use Only
Date
Site Orientation Complete?
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
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Orientation current
Job Safety Analysis
Complete this section in order to identify each activity, its hazards, controls and person accountable for ensuring safe activities.
Sequence of Activities
Potential Hazards
Recommended Safe Procedures
Accountable Parties
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20 Name: contractorpermittowork 2015-0320.xlsx
Template
Template Issue Date: March 18, 2015
Contractor Work Permit
v4.0
Hazard Assessment
Identify each hazard that could cause injury or incident when the task is performed.
Hazardous Chemical Exposure
Ergonomic Exposure
Physical Exposure
 Flammable/Combustible
 Repetitive Motion
 Noise
 Site Security/Workplace Violence
 Corrosive/Oxidizer/Reactive/Toxic
 Body Strain/Positioning
 Heat/Cold/Temperature
 High Pressure Washers
 Inhalation/Eyes & Skin
 Pushing/Pulling
 Inclement Weather
 Hand/Power Tools
 Pesticides
 Other: _____________________
 Hot Work/Welding/Cutting/Burning
 Low Illumination
 Confined Spaces
 Catch/Pinch/Strike Points
 Stored Hazardous Energy (LOTO)
 Electricity (110V Or Less)
 Insects/Animals/Plants
 Falls From Heights/Same Level
 Electricity (110V Or More)
 Mold/Fungus
 Utilities
 GFCI Required
 Viral/Bacterial
 Machinery/Guarding
 Conveyor Belts
 Hazardous Waste Collection
 Radiological Exposure
 Powered Industrial Vehicles
 Slippery Surfaces
 Hazardous Waste Shipment/Disposal
 Non-Ionizing Radiation - UV, Sunlight
 Manual Material Handling
 Personnel Transfers
 Universal Waste
 Ionizing Radiation (Gamma, X-Ray)
 Ladders/Scaffolding/Aerial Lifts
 Projectiles/Dust
 Pharmaceutical Waste
 Other: _____________________
 High Temperature Materials/Surfaces
 Other: _____________________
 Asbestos/Lead/Carcinogens
 Paint
Biological Exposure
 Other: _____________________
Environmental Exposure
 Spills/Discharges
 Compressed Gases/Hazmat Storage
 Other: _____________________
 Traffic/Driving
Required Safety Equipment and Controls
Identify the appropriate measures taken to reduce or eliminate the risk of injury or incident when performing the task.
Engineering Controls
Administrative Controls
PPE
 Guard Rails
 Qualified For Task
 Filtering/Face piece/Respirator/Dust Mask
 Electrical Insulated Footwear
 Machine Guards
 Trained/Certified For Task
 Elastomeric Face piece
 Boot Covers
 Sound Barriers/Baffles
 Work Plan
 FR Rated Clothing
 Cut-Resistant Gloves
 Enclosure/Isolation
 Hot Work Permit
 Tyvek or Srarnex Coveralls
 Material Handling Gloves
 Fire Extinguishers/Systems
 Confined Space Entry Permit
 Chemical Apron
 Nitrile Gloves
 GFCI/Equipment Grounding
 Lockout/Tagout
 Welding Shield/Mask & Leathers
 Food Handling Gloves
 Anti-Skid Ergonomic Matting
 Equipment Inspection Sheets
 Sunblock/Sunhat
 Personal Fall Arrest System
 Other: _____________________
 Material Safety Data Sheets (MSDS)
 Hard Hat
 Arc Flash Protection Kit
 Hazard Warning Signs
 Ear Plugs
 Other: _____________________
 Fire Watch
 Ear Muffs
 Emergency/Evacuation Plan
 Proper Tools/Equipment
 Safety Glasses With Side Shields
 Eyewash/Shower
 Communications
 Chemical Goggles
 First Aid Kit / AED
 Proper Lifting Techniques
 Face Shield
 Fire Extinguishers
 Training Program
 Steel Toe Boots
 Spill Containment
 Other: _____________________
 Slip Resistant Shoes
Contingency Planning
 Severe Weather Shelter
 Pandemic Plan
 Other: _____________________
Revision/Change Control
Complete this section to note any changes or deviations from the job safety analysis previously completed.
Nature of Change
Name
Signature
Date
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For Sodexo Office Use Only
Reviewed and Approved by (print):
Signature:
Date:
Template Name: contractorpermittowork 2015-0320.xlsx
Template Issue Date: March 18, 2015