I&TS HSW Management Sub-System
3.1-07FO3 General Permission to Work Form
The purpose of this General Permission to Work (GPTW) is to ensure that adequate controls are implemented to protect the safety of persons
conducting, or who may be in the vicinity of high-risk work being undertaken and to protect University property from damage.
General Permission to Work (PTW) Number
(UoA to complete)
In the event of an Emergency, all GPTW’s are immediately suspended. All persons must assemble at the nearest nominated assembly point.
The GPTW must be re–authorised (Signed) by the I&TS GPTW Issuer before work resumes.
1.
CONTRACTOR DETAILS
Company undertaking the work:
Person undertaking the work
& phone number:
Supervisor name
& phone number:
Principal Contractor Company:
Principal Contractor Contact name
& phone number:
2.
PROJECT DETAILS
University Project / Job No.
(if applicable):
Location of Work: (inc.
Campus/Building/Room:
Planned Work Activity:
Estimated Duration of the PTW:
3.
Date from:
Time:
Date to:
Time:
WORK DETAILS
Tick applicable boxes:
☐
Working at Heights > 3 metres
☐
Working on any de-energised electrical infrastructure, on, or
upstream of a LV electrical distribution board (working on
ANY live electrical infrastructure is strictly prohibited)
☐
Roof Access (inc EME equipment)
☐
Building Penetration >25mm
☐
Removal or disturbance of Asbestos
☐
Earth Penetration >300mm
☐
Work where high risk work licence is required by Legislation (Reg 81)
☐
Other ………………………………………………………
☐
Isolation of Fire Indicator
Panel
4.
ie Boom-type EWP, scaffold, dogging & rigging, crane/hoists, forklift, pressure equipment operation
(ie entering hazardous spaces)
ISOLATIONS REQUIRED
Isolation Forms Attached:
(if applicable)
☐
Isolation of Essential Services (water,
gas, electricity, mechanical, etc)
Isolation of Fire
Suppression Systems
☐
5. GENERAL REQUIREMENTS FOR SWMS/JSA
The person in direct control acknowledges that the items related to GPTW (below) have been considered and included in the attached SWMS/JSA.
All items must be ticked or marked N/A ( or N/A):
 or
 or
GENERAL INCLUSIONS:
N/A
N/A
Company Details; name address and ABN
Names of workers consulted in developing the SWMS/JSA
Reference to relevant WHS Legislation, COPs and Standards
Worker responsible for ensuring implementation, monitoring &
compliance is identified
Permits, licences and training is documented
RISK & HAZARD IDENTIFICATION & CONTROL
A Sign off sheet for workers
Tasks are set out in a logical step-by-step sequence
Risks and controls are clear and specific
 or
N/A
 or
N/A
All task specific hazards are identified
Working Outdoor risks (including weather) are identified
Workers are able to add site specific hazards
Site Access & Egress risks are identified
Essential/fire services isolation needs are identified
Environmental concerns are identified
Plant and equipment to be used is identified
Hazardous Chemicals to be used are identified
Adequate controls & PPE are identified to eliminate or reduce the risk
Adequate controls & PPE are identified to eliminate or reduce the risk
Isolation Request form must be referenced as controls
Pre start inspections & PPE must be referenced as controls
Warning
Authorised by
Filepath
Traffic management and PPE must be referenced as controls
Site security and maintenance of disability access must be considered
EPA compliant clean-up must be referenced as controls
Safety Data Sheets and PPE must be referenced as controls
This process is uncontrolled when printed. The current version is available on the I&TS Website.
Director of Infrastructure & Chief Information Officer
Document1
Effective Date:
Review Date:
January 2014
January 2019
Version:
2.0
Page: 1 of 3
I&TS HSW Management Sub-System
3.1-07FO3 General Permission to Work Form
General Permission to Work (PTW) Number
6.
(UoA to complete)
WORK SPECIFIC REQUIREMENTS FOR SWMS/JSA COVERED BY THIS GPTW
Complete the section that relates to the Work Details ticked in Section 3. All items (in the section) must be ticked or marked N/A ( or N/A):
The person in direct control acknowledges that the items related to GPTW (below) have been undertaken and included in the attached SWMS/JSA.
 or
 or
WORKING AT HEIGHTS >3 METRES
N/A
N/A
Ladders, Elevated Work Platforms (EWP)and/or scaffolding complies
System in place to prevent tools/equipment falling
with relevant Standard
Fall protection/arrest equipment identified and conforms to
Rescue plan provided (required when fall arrest utilised)
Standards/anchor points rated to 15kn identified
 or
 or
ROOF ACCESS
N/A
N/A
Roof Register sighted & Roof has been load tested/verified to support
Regular communication between working party and
weight (as applicable)
nominated emergency contact.
Where the Roof Register identifies EME (telecommunications or other
Where the Roof Register identifies Unprotected roof edges,
RF transmission) equipment, no-go zones are acknowledged
holes and/or openings and steep or slippery surfaces, risk
Where the Roof Register identifies Fume exhaust flues, risk is
is assessed and controls are in place. Fall protection
assessed and isolation has been arranged
(which conform to Standard) & a system which prevents
tools/equipment from falling are provided. Standby person
Where the Roof Register identifies Fragile roof materials, risk is
is provided and rescue plan is in place.
assessed and controls are in place
 or
 or
EARTH PENETRATION > 300MM
N/A
N/A
Excavation secured from public access including
All underground services located and marked
inadvertent entry
Nature of ground investigated (soil/rock, wet/dry etc)
Atmospheric conditions considered
Possibility of flooding reviewed (drain, run-off etc)
Rescue plan provided where there is a risk of cave in
Trenches >1.5m deep shored, shielded or benched to
prevent cave in
Spoil pile safely located (preferably on low side of excavation)
Work arranged so persons do not work alone in trenches >1.5m deep,
or where SWMS/JSA has second person as control measure
ELECTRICAL INFRASTRUCTURE
Trenches <1.5m – stability of excavation addressed
 or
N/A
Electrical infrastructure & associated hazards are identified including
area clear of wet conditions, combustible and flammable materials
Where required, written permission from SA Power Networks has
been obtained/electrical network operator notified
All conditions specified by SA Power Networks
and the Technical Regulator are complied with
For work on live circuits a risk assessment has been completed
justifying the need for the work and there is a trained safety observer
present at all times who is competent in low voltage rescue.
BUILDING PENETRATION >25MM
 or
N/A
Where required a trained safety observer and
communication system is in place
Lock out/Tag out procedures are in place for isolation of
affected plant & infrastructure
The treatment of all cables as energised until positive tests
are made which prove the cable is de-energised
Identification of equipment downstream of isolation which
could be effected ie essential machinery/research activities
 or
N/A
 or
N/A
Penetration has been assessed for breakthrough
risks/hazards, flooding and effect on structural conditions
All services located and marked including communication services
Asbestos Register sighted & local risks assessed
 or
N/A
ASBESTOS
SafeWork SA approval & EPA disposal licences attached
 or
N/A
Asbestos removal control plan submitted and attached
Notification regarding the removal of asbestos has been
provided to staff, students and workers in the area.
Class of asbestos removal has been determined
Asbestos Register sighted & local risks assessed
WORK WHERE HIGH RISK WORK LICENCE IS REQUIRED
 or
N/A
 or
N/A
Level of High risk work licences required to perform task
High risk work licences sighted
SWL for lifting equipment is assessed & has current inspection
Where required plant has a current registration
Warning
Authorised by
Filepath
This process is uncontrolled when printed. The current version is available on the I&TS Website.
Director of Infrastructure & Chief Information Officer
Document1
Effective Date:
Review Date:
January 2014
January 2019
Version:
2.0
Page: 2 of 3
I&TS HSW Management Sub-System
3.1-07FO3 General Permission to Work Form
General Permission to Work (PTW) Number
7.
(UoA to complete)
GPTW REQUEST (GPTW Holder)
ALL ITEMS MUST BE TICKED
This acknowledgement signifies a formal request to commence activities involving one or more specified high-risk works. I request this GPTW be
acknowledged and registered by the relevant University of Adelaide GPTW Issuer. As the person requesting this PTW, I hereby certify that:
☐
I have developed / reviewed the attached SWMS/JSA for the work covered by this GPTW.
☐
All work being undertaken covered by this GPTW meets the current South Australian WHS legislative requirements.
☐
I am competent to co-ordinate this work activity in accordance with the attached SWMS / JSA.
I shall ensure that all persons required to carry out the work have: the relevant licences; attended the current University of
Adelaide Contractor Induction; been consulted and understand the requirements of the SWMS / JSA and the GPTW.
I shall implement all planned and necessary controls to ensure the health and safety of all persons who may be affected by the
activities.
☐
☐
☐
I shall monitor the identified hazards and control strategies throughout the work activities.
☐
I have submitted this GPTW to the relevant PCBU/Principal Contractor to ensure that controls are adequate.
GPTW Holder
Name:
8.
Date:
Time:
Signature:
PRINCIPAL CONTRACTOR/ PCBU CONTRACTING THE WORK TO THE GPTW HOLDER
ALL ITEMS
MUST BE
TICKED
As the Principal Contractor (where someone other than the University has engaged the GPTW Holder)/ PCBU (where the University has engaged the
GPTW Holder) commissioning the work, I have reviewed the attached SWMS/JSA (and kept a copy) for the work covered by this GPTW to ensure:
☐
Hazards and risks have been identified and adequate controls measures are implemented.
☐
Workers undertaking the work are trained and competent to undertake this work in accordance with the attached SWMS / JSA.
☐
All work being undertaken covered by this GPTW meets the current South Australian WHS legislative requirements.
PCBU/Principal
Contractor Rep:
9.
Date:
Time:
Signature:
I&TS GPTW ISSUER
The above criteria have been addressed and the work is authorised to commence in accordance with the SWMS / JSA and identified control
measures. As the I&TS Permit Issuer, I hereby acknowledge that:
☐√
I have allocated this GPTW a number and scanned to the GPTW register in the relevant area.
☐
For Asbestos work; The UoA Asbestos Consultant and the Branch/Faculty Manager of the affected/adjacent areas have been notified.
GPTW Issuer
UoA
Date:
Time:
Signature:
10. CLOSE OUT
As the GPTW Holder, I hereby acknowledge that:
☐
All Isolations have been removed and/or reinstated, all workers have vacated the space and the area has been left in a safe condition.
☐
All near miss/hazards/incidents have been reported.
☐
The PCBU/Principal Contractor has been informed that the work is complete and of the close out this GPTW.
☐
Asbestos Removal Documentation has been provided i.e. Air monitoring results/clearance certificate, transport and disposal certification.
GPTW Holder
Date:
Time:
Signature:
As the GPTW Issuer, I authorise the closure of this GPTW and will scan it to the GPTW register in my area:
GPTW Issuer
Original – Retained by GPTW Holder
Warning
Authorised by
Filepath
Date:
Time:
Signature:
Copy – Retained by GPTW Issuer
This process is uncontrolled when printed. The current version is available on the I&TS Website.
Director of Infrastructure & Chief Information Officer
Document1
Effective Date:
Review Date:
January 2014
January 2019
Version:
2.0
Page: 3 of 3