Attachment 3 - 2021 DOE Work Control Permit.pdf

DOE Headquarters Work Control Permit

Updated 11/6/2017

1. GENERAL INFORMATION

DOE Project Manager:

Phone Number: Organization:

Contractor Project Manager:

Phone Number: Company Name:

Contractor Project Supervisor:

Phone Number: Company Name:

Building: Room #:

Mechanical Space #:

Provide a Brief Description of the Task/Activity/Work to Be Performed:

Anticipated Work Times

□ During Business Hours (6 am – 8 pm)

□ After Business Hours (8 pm – 6 am)

□ On Weekends/Holidays

Contractor/Sub-Contractors to Perform Work:

Complexity Level:

□ Simple/ Straightforward

□ Complicated/ Few Steps

□ Complex/ Multiple Steps

Anticipated Start Date: Anticipated End Date: Coordination Level:

□ Singular Relationships/ Interactions

□ Several Relationships/ Interactions

□ Multiple Relationships/ Interactions

2. DEVELOP JOB HAZARD ANALYSIS (see page 2)

□ Worker Safety and Health Plan is current and has been approved.

□ Job Hazard Analysis (JHA) is complete and attached.

□ Required permits are complete, processed and attached.

3. AUTHORIZATION

Authorizations for Permitted Work (Signature & Date required. Signature means that the safety, health and environmental hazards have been identified, appropriate procedures are in place to control the hazards, appropriate coordination has been made, and the individual is satisfied that work may proceed in accordance with these procedures.)

Title Name (Print) Signature Date Project Supervisor

Contractor Project Manager

DOE Project Manager

Building Manager

HQ Industrial Hygiene & Safety

Date Authorized to Start:

schotam Text Box

GTN-WP-20-06

2. JOB HAZARD ANALYSIS

No. Task Step Hazards Controls

DURING WORK ACTIVITY

4. CONTRACTOR TEAM PRE WORK BREIFING

Part 1: □ Project supervisor acknowledges that all plans, hazards, and controls outlined in the JHAs have been reviewed with all workers, including subcontractors.

Part II: □ DOE Work Permit is posted at jobsite

Part III: □ Supervisor will provide contractors with daily safety tool box talks and review the planned day’s work activities.

Signature below indicates that individuals have read and understand the hazards, work controls, coordination, complexity, and permit requirements.

Project Supervisor Name:

Signature:

5. PROBLEMS/CONCERNS/CHANGES TO WORK CONTROL PERMIT OR JHA

Document any problems, concerns, or changes that are raised and what was done to correct them; including work stoppage. Share these with Building Manager and DOE Safety.

List any Problems/Concerns/ Changes Remedy PM Initials 1.

2.

3.

4.

WORK ACTIVITY CLOSE-OUT

6. PROJECT COMPLETION & REVIEW

Signature means that all work was completed in accordance with permit. Any changes were documented.

Things to do differently next time:

Project Supervisor Signature & Date:

Contractor Project Manager Signature & Date:

DOE Project Manager’s Signature & Date:

Submit completed form to the Office of Industrial Hygiene & Safety.