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Issue Date: March 2008

Power City Electric
Revision Date: May 2014
Safety Management System Revision No. 1
Policy Doc: SWA
Stop Work Authority Form Forms / Permits: SWAF
Preparation: Safety Mgr. Authority: President Issuing Dept: Safety Page 1 of 1

ATTN: Project Manager, Jobsite Supervisor, Project Safety Representative, Safety Department

PCE Job #: Date:

Job Name / Location:

The “Stop Work Authority” process involves a stop, notify, correct, and resume approach for the resolution
of a perceived unsafe condition, act, error, omission, or lack of understanding that could result in an
undesirable event, or cause potential harm or injury to personnel, property, or the environment.

The specific hazard is described as: Photos attached: Yes No

Submitted by:
Employee Signature Date Time

( )
Printed Name Phone

Received by:
Supervisor Signature Date Time

Investigation and disposition / resolution of safety concern and/or work stoppage:

Reviewed by:
PCE Safety Representative Date Time

I do hereby acknowledge that I am satisfied with the disposition / resolution of safety concern.

Employee Signature Date Time

The Company’s established SWP supports greater employee engagement in safety, increasing safety
awareness, encouraging workers to look out for each other, fostering greater communication among co-
workers and supervision, and broadening employee focus and emphasis on safety.

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