The document outlines a de-shuttering work permit process, detailing project information, permit issuance requirements, and necessary safety prerequisites. It includes checklists for the initiator and evaluator to ensure compliance with safety measures and confirms the competence of personnel involved in the task. Additionally, it covers areas for authorization and completion/cancellation of the permit, ensuring the work area is safe for operations.

1. DE-SHUTTERING WORK PERMIT
Page 1 of 2 Form # HSEQ-DSWP (Rev 2 - Mar 23)
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
☐ ☐ ☐

2. DE-SHUTTERING WORK PERMIT
Page 2 of 2 Form # HSEQ-DSWP (Rev 2 - Mar 23)
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 (HSE & QC
Team):
Designation:
Signature: Date /Time
Comments (if any):
5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:
6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time