PATOS FORM EHS-PR-03.

F01

Activity/Task
Date Company Project Location
Complete the PATOS Questionnaire
If a hazardous substances / chemicals is to be used, do you have the MSDS available? NO YES
Equipment & Tools to be used: ___________________________________________________________________

Does the task require a permit or other document approval? NO YES Indicate which

Excavation Permit Confined Space Permit Isolation Permit Lifting Permit

Working Near Overhead Power Line Permit Working at Height Permit Hot Work Permit
Demolition Works Permit Formwork Inspection & Concrete Pouring Permit Gondola Operations
Scaffold Inspection and tag
Logical Steps in Task Hazard/ What controls are required to manage the Is the hazard
Unwanted Event (What could go wrong,) hazard? controlled
(Consider Hierarchy of Controls) adequately?

Document Number – Title Owner Date Approved Revision Status Next Review Date
EHS-PR-03.F01 PATOS Form EHS dd/mm/yyyy Rev 00 dd/mm/yyyy

Only Authorized Printed Version Is Deemed To Be Controlled Page 1 of 2

 Orientation and sign off by all persons involved in work under this PATOS is - Before Commencing task; and
Mandatory - If additional hazards and controls have been identified
Name: Signature: Date: Name: Signature: Date:

Responsible Engineer /
Signature: Date:
Supervisors Name:
EHS Approver Name: Signature: Date:
Who is person responsible to Sign off by responsible person to state that
Control actions from PATOS implement this control? controls have been implemented prior to
commencing step in task

Yes No
If job is still in progress or incomplete: Have you discussed this PATOS with the oncoming Supervisor?

Document Number – Title Owner Date Approved Revision Status Next Review Date
EHS-PR-03.F01 PATOS Form EHS dd/mm/yyyy Rev 00 dd/mm/yyyy

Only Authorized Printed Version Is Deemed To Be Controlled Page 2 of 2