PERMIT TO WORK
P.T.W. Number:
SIGN ON/OFF SHEET – BAC Controlled Work Authorisation Works
Section 1 – General Details
Work Coordinator /
Contractor Representative:
Name (First & Last)
Contact #
Name (First & Last)
Contact #
Work Coordinator /
Contractor Representative:
Section 2 – PTW / Safe Access Instructions
As a person required to work under this PTW you must satisfy the requirements listed below and then complete the sign on/off details required.
You must sign on at the commencement and completion of your involvement in the work. If your involvement exceeds the duration of one working shift,
then as a minimum you must sign on at shift commencement and sign off at shift completion.
Note: If you are entering a confined space as part of this PTW, you will need to sign onto the Confined Space Entry Permit.
1.
2.
3.
4.
5.
6.
Contact the Work Coordinator / Contractor Representative, obtain PTW / Safe Access Instructions and obtain permission to commence work.
Ensure you understand the scope of the PTW, your role / tasks and any plant isolation requirements relating to the PTW.
Ensure you are aware of all hazards that you may encounter and the means of effectively managing them. Report any pre-work concerns you
may have.
Ensure you are familiar with the safety procedures and PPE requirements for the tasks in which you are involved. Ask questions if you are
unsure.
Ensure you are able to perform the work in a manner that does not compromise your own personal safety or the safety of others.
Notify other relevant Workers and the Work Coordinator / Contractor Representative immediately if you become aware of a new hazard.
Section 3 – Work Personnel Sign On / Off (except for those entering Confined Spaces)
SIGN ON
Print name (First & Last)
Date
Time
Signature
SIGN OFF
Date
Time
Signature
IF THIS TABLE IS FULL, ASK THE WORK COORDINATOR / CONTRACTOR REPRESENTATIVE FOR ANOTHER SHEET – DO NOT WRITE OUTSIDE OF THIS TABLE
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