ISOLATION PERMIT
Issue Date: 01/07/2016
ReviewDate:01/07/2018
This permit is valid for the time specified on the permit and must be

Completed by the person performing the work prior to commencement of any work requiring isolation

Used in conjunction with a SWMS or Safe work instruction

Checked by the GPNSW Representative prior to work commencing

Carried and provided when requested

Provided to the GPNSW Representative on completion of work for sign off
Part A Work Details
Name of permit requestor
Contact Number
Location of work- Building
room no
Description of work
Business name
Date of work
☐Gas
☐Electrical
☐other _ provide detail
Note this excludes a Fire Indicator Panel which has a separate permit.
Permit validation period
From Date: /
/ Time:____am/pm
To Date:
/
/Time:____am/pm
GPNSW Authorised
Name
Permit order number
Representative
from objective
Position
Part B: Assessment and Controls
System to be isolated
Assessment
 Safety requirements have been assessed and controls included in safe work method
statements
 The energy source can be adequately and safely isolated
 Any safety equipment to be used have been maintained and checked prior to use
 Persons conducting the work are trained and licenced and competent
 There is adequate fire protection for the work being conducted.
Controls
A Work Method Statement has been developed and is specific to and adequate e for the
work to be conducted
 Controls in the Work Method Statement are implemented , including (but not limited to)
 Lock outs and tags installed to isolated valves or outlets
 Fire protection equipment installed
 Area barricaded and signed
 Working on live electrical installations in accordance with state legislative requirements
 Ladders or scaffolds are appropriate for the work, inspected and secure
 Persons who made by affected by energy isolation have been notified(eg employees,
customers or contractors)
Yes
N/A
Yes
N/A
Part C: Acknowledgement (persons performing the work)
I certify that all necessary precautions as detailed in the permit have been taken to make the area safe for the
permitted work
Contractor Name
Company
Signature
Date: /
/ Time:____am/pm
I have reviewed this permit authorisation and authorise the work to proceed as indicated . I confirm that no
conflicting work will be undertaken concurrently with this task
GPNSW Representative Name/Signature
Date: /
/ Time:____am/pm
Persons Entering/Vacating Isolated work area (attach separate sign in sheet if more room required)
Name
Company
Date
Custodian: WHS Manager
Approved by: Place Management
Number: SMS-02-FM- A1175702
Uncontrolled copy when printed
Time
in
Time
out
©GPNSW
Version: 1.1
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ISOLATION PERMIT
Part D:Completion
I certify the job has been done and the area made safe
Contractor Name
Company
Signature
Date: /
Site Manager
I acknowledge that the work has been completed and the permit is returned
Name
Position
Signature
Date: /
Issue Date: 01/07/2016
ReviewDate:01/07/2018
/ Time:____am/pm
/ Time:____am/pm
Part E. Emergency Authorisation for Lockout release
In the event that the person who put the lock out in place is unable/unavailable to remove the tag and lock, the
following procedure is to be followed to authorise the release of the lockout;
The Authorised Officer and the Contractor have checked
☐The work area is clear of personnel tools and equipment
☐It is safe to remove the tag and lock out device and
☐It is safe to re energise the energy source/re-activate the plant
Name
Signature
Date
Time
Contractor
Authorised Representative
Custodian: WHS Manager
Approved by: Place Management
Number: SMS-02-FM- A1175702
Uncontrolled copy when printed
©GPNSW
Version: 1.1
Page 2 of 2