Dear Anonymous
You have desired to have a sample PTW (Permit To Work). It may pointed out for awareness of all that a PTW is a written document signed by an authorised person which authorises an employee/worker/contractor to carry out a maintenance/repair activity on plant/equipment connected to a system with electrical power. I am appending below a sample format of PTW :
Name of the Company_______________________
Department
Date_____________ Time of Issue_____________ PTW No.___________
This PTW is being issued to Mr______________, Designation__________, Employee No.____________ or Mr______________, Designation_______, employee of Contractor M/s____________________ to carry out the maintenance/repair work of ____________________ at plant/machine/station etc (as applicable) on date______________ from (time)___________ to ____________ (time).
The work will be started only after informing and obtaining written clearance from the ____________ Department that the work area has been disconnected from the connected source of power supply and now it is safe to work. After completion of the maintenance/repair work the information will be given to the said Department____________________ who will reconnect the plant/equipment/work area with the power system.
The executing employee/contractor will check the working of the plant/equipment after repair/maintenance and the return the PTW to the issuing authority giving the time of start and time of completion of work with date.
Name and signature of the Issuing Authority with rubber stamp
Details of work done:
1. Clearance obtained from __________ Department at __________ (time)
2. Maintenance/Repair work started at ________ time and completed at __________ time.
3. Information of completion given to _________ Department at __________ time.
4. Working of plant/equipment checked and found OK. In case any defect is noticed then it will be informed to the Issuing Authority before return of PTW for obtaining further directions.
Signature of the employee executing the work
with rubber stamp.
The above format can be adjusted as per requirement of the industry.
Hope this will serve your purpose and it will also be useful for general awareness of the members and other readers.
With regards
C.M. Lal Srivastava
9818680671