PERMIT TO WORK FORM

PTW/OSHA/09 :…………..

SECTION 1 - DETAIL OF JOB APPLICATION (To be filled-up by Applicant)

Name of Requestor:
Name of Applicant: Date:

Site/ Company Name & Address:

Telephone No.: Name of Supervisor In Charge:

Work Title: Location of Work:
Description of Work:
Duration of PTW: From: Date: To: Date: Time:

Status of PTW: Open Last date: ____________________

Name of Workers (Please provide additional list if the space is insufficient)
No. Name I/C No.
1
2
3
SECTION 2: TYPE OF WORK/ ACTIVITIES (Please /)
Working At Height (> 3 meters) Gondola Operations
Entry to Confined Spaced Genie/Dino Lift Operations
Hot Work
Energized Electrical Scaffolding Erection Chemical Handling Other:______________________________

SECTION 3: POTENTIAL HAZARDS

Electric Shock Back pain Falling Objects Occupational diseases
Burn (eye, skin,etc) Fatality Animal bites (snake, etc) Occupational poisoning
Suffocations Hand/Leg Cramp Explosion/ burst Others (please specify):
Hand Stuck Bacteria infection Radiation
Chemical exposure/ inhale Heat/ Cold exposure Vibration
Fall from height Slippery Environment (lighting, wind, etc
Major property damage Body injury (cut. scretch) Drowning
SECTION 4: PPE / SPECIAL REQUIREMENT (Please /)
Safety harness Goggle Welding apron Safety shoes
Lifeline Faceshield / visor Spill kit Glove
Ascender & decender Discharge rod First aid kit Safety helmet
Gaseous test by Authorised Gas Tester
HT suit: overall, visor & boot Earmuff / earplug HT test pen
Mask / respirator/ SCBA Other (Pls state: _________________)
SECTION 5: IMPORTANCE NOTICE/ REMINDER
i) Permit to Work must be reviewed,approved and terminated by Facility Maintenance (FM) / CIMB OSHA Unit
ii) Approved Permit to Work (PTW) must be available at all times during the work
iii) The applicant must comply with the OSH Act 1994 & other stipulated rules & regulations thus CIMB Group Safety & Health Policy & Procedure Manual.
vi) Failing which, PENALTY will be imposed to all violators
v) Appropriate Personal Protection Equipment (PPE) must be provided to own workers
vi) A copy of PTW shall be forwarded (by GFM) to OSHA and FM Department, if necessary for security controller
vii) Ensure all appointed staff/ workers are briefed on relevant safety requirements and procedures
viii) Any accident/incident occur at respective site must be reported to CIMB OSHA Unit ASAP using CIMB Incident Report Form (OSH 1)
SECTION 6: APPLICANT DECLARATION
I/ We confirm that we have read and fully understood the terms and conditions above and hereby agree to strictly comply with rules and
regulations as well as safety requirements set by the building owners and GFM. I / We shall brief all my workers involved in this work and
ensure that they are carry out work safely at all times.
Applicant Signature: Date:

SECTION 7: FOR GFM VERIFICATION AND APPROVAL

i) PTW application must be submitted and approved by authorised personnel before commencement of work
ii) PTW is required for all type of works defined in CIMB Group Safety & Health Policy & Procedures Manual.
iii) Validity of this Permit to Work is only 7 DAYS from the date of issuance. (Additional extension : _____ days)
iv) The pre-entry checklist below is checked and verified
v) Please submit complete PTW by hand to MBC-GFM Office at level 23 /Fax : 03-26910603 or E-mail to :Mazhairil@globalfm.com.my
SECTION 8: PERMISSION
Allowed Not allowed Pending permission. Reason:_________________________________________
No Description Yes No
i) Complete Permit to Work has been submitted within the required time frame
ii) All assigned workers are briefed on relevant safety/ SOP training/ emergency response plan
Appropriate PPE are provided/ wear; Safety shoes, helmet, goggles, earplug/ earmuff, etc (please
iii)
specify)
iv) Vendor Instruction Guideline is understood and signed off
v) LOTO Devices are obtained/ available (for energized electrical work only)
Checked & verified by Name Signature Date
GFM Representative
FM Reprsentative
OSHA Representative
SECTION 9: CLOSING WORK PERMIT
Checked & verified by Name Signature Date
GFM Representative
FM Representative
OSHA Representative