1. Project Information: (To be filled by initiator/originator) Project Name: Permit No.: Project Location: Requesting Contractor/Company 2. Permit Issuance Details: (To be filled by initiator/originator) THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE Description of Task: Location, Grid Line & Floor / Level: No of persons working : Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date: 3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator) Checks Yes-No-NA Checks Yes-No-NA Method statement and Risk assessment developed, approved and communicated? ☐ ☐ ☐ Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐ Engage competent Scaffold erector and Carpenters for the de-shuttering task? ☐ ☐ ☐ All nails shall be removed from formwork materials upon dismantling or at least it shall be bent with hammer to avoid pricks? ☐ ☐ ☐ Pre-start briefing shall be done on daily basis before starting the work in each shift? ☐ ☐ ☐ Protruding steels shall be protected by rebar cap or fabricated wood cap. Immediately relocate dismantled materials from the activity area? ☐ ☐ ☐ Ensure de-shuttering area is illuminated with task light? ☐ ☐ ☐ Do not leave any struck formwork materials hanging in concrete (i.e. plywood, wood). Peel off the duct tape used to cover the plywood gaps ☐ ☐ ☐ Do not throw form work materials from top to ground level? ☐ ☐ ☐ Do housekeeping every one hour. Stack the stripped off materials according to its size and type separately away from access routes and pedestrian walk ways ☐ ☐ ☐ Ensure two men handle each form work material to bring down safely and stack them safely? ☐ ☐ ☐ Ensure the availability and use of Safety Helmet, Hand gloves, clear eye protection, Safety Harness and ear plug. ☐ ☐ ☐ Ensure safety harness is hooked to the scaffold ledger above shoulder level while de-shuttering. ☐ ☐ ☐ Ensure Lifting plan implemented if any lifting activity for de-shuttering work. ☐ ☐ ☐ Ensure work platforms without openings and ensure proper access / egress. ☐ ☐ ☐ Restrict other unnecessary movements. Ensure de-shuttering area is barricaded with no entry warning signs? ☐ ☐ ☐ De-shuttering shall be done in same fashion as explained by form work designer and trained by respective section Engineer? ☐ ☐ ☐ Others( Specify) ☐ ☐ ☐ Dismantling of frames and support of formworks shall be from top to bottom provided with safe access & working platform? ☐ ☐ ☐ ☐ ☐ ☐ 4. Acknowledgement by Initiator and Evaluator: ☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely. Initiator/Originator Name: Designation: Signature: Date /Time: ☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity Evaluator