Corporate Safety – Forms
High Voltage Access Permit
No:
1. Switching Sheet No.:
3. Nominated Issue (time/day):
2. Work Area Location:
4. Anticipated Surrender (time/day):
5. Issued to:
6. Access to the following equipment/High Voltage Apparatus:
7. Work Details:
8. Description of Isolation Points with DNOs attached:
9. Location of Operator Earths with DNOs attached:
10. Other Precautions taken:
Taping off
Work Area Signs
Barriers in place
Live & Dead Board
Roping off
Live HV Lines & Apparatus above Board
Other (please specify)
11. Nearby Live HV at the work area
12. ISSUE OF ACCESS PERMIT
Approval by
Name of Switching Coordinator:
Switching
Name:
Operator
(please print)
Signature:
Time:
Date:
13. RECEIPT OF ACCESS PERMIT
I acknowledge that I only have access to the apparatus listed above and will have no
difficulty in keeping clear of apparatus not covered by this Permit and will not alter Isolation
Points, and other precautions in place.
Recipient
Name:
Signature:
Time:
Date:
(please print)
No:
Doc no.
Doc owner:
Version date:
Trim ID:
FRM-00439
24/01/2014
Doc approver:
Rev no.
Y Dong
Manager, WH&S
2
Page 1 of 4
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety – Forms
High Voltage Access Permit
14. WORK GROUP SIGNATURES
I acknowledge that I only have access to the apparatus listed on page 1 and
will have no difficulty in keeping clear of apparatus not covered by this Permit
and will not alter Isolation Points, and other precautions in place.
Name (please print)
Signature
Time
Is a supplementary Work Group Signature page (19) in progress?
I acknowledge that I no longer have access
to the apparatus listed on page 1 and will
regard the apparatus as being live.
Date
Signature
Yes
No
Time
Sheet No.:
15. TRANSFER OF ACCESS PERMIT
Outgoing
Name:
Recipient
(please print)
Ingoing
Name:
Recipient
(please print)
Signature:
Time:
Date:
Signature:
Time:
Date:
16. WORKING EARTH SCHEDULE
#
Location of each set of Working Earths
ON
Time
OFF
Date
Time
Date
17. ABNORMALITIES
No:
18. SURRENDER OF ACCESS PERMIT
Doc no.
Doc owner:
Version date:
Trim ID:
FRM-00439
24/01/2014
Doc approver:
Rev no.
Y Dong
Manager, WH&S
2
Page 2 of 4
The controlled version of this document is registered. All other versions are uncontrolled
Date
Corporate Safety – Forms
High Voltage Access Permit
(are supplementary pages attached and signed off?)
I acknowledge that I no longer have access to the apparatus listed on page 1 and will regard the apparatus as
being live.
Recipient
Name
Signature:
Time:
Date:
(please print):
No:
19. WORK GROUP SIGNATURES SUPPLIMENTARY PAGE
I acknowledge that I only have access to the apparatus listed on page 1 and
Doc no.
Doc owner:
I acknowledge that I no longer have access
Version date:
Trim ID:
FRM-00439
24/01/2014
Doc approver:
Rev no.
Y Dong
Manager, WH&S
2
Page 3 of 4
The controlled version of this document is registered. All other versions are uncontrolled
Corporate Safety – Forms
High Voltage Access Permit
will have no difficulty in keeping clear of apparatus not covered by this Permit
and will not alter Isolation Points, and other precautions in place.
Name (please print)
Doc no.
Doc owner:
Signature
Time
Date
to the apparatus listed on page 1 and will
regard the apparatus as being live.
Signature
Time
Version date:
Trim ID:
FRM-00439
24/01/2014
Doc approver:
Rev no.
Y Dong
Manager, WH&S
2
Page 4 of 4
The controlled version of this document is registered. All other versions are uncontrolled
Date