You are on page 1of 2

ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issued For General Use Reference No. HSE-PRO-06-F02 Serial No. Page 1 of 2

FORM Radiography Permit To Work

0.0

Section 1. Permit Information 1.1 Permit No. 1.2 Permit Validity from to 1.3 1.4 1.5 1.6 Issued to Issued by Job Location: Work Activity: Permit Holder Permit Authority NAME / SURNAME NAME / SURNAME HH:MM HH:MM Company on date on date DD/MM/YYYY DD/MM/YYYY

Section 2. Required Controls 2.1 X-Ray Generator: Model: Radioactive Isotope 2.2 Isotope: Type of radiation
(tick applicable)

Maximum Tube Voltage kV: Manufacturer: alpha Film Badge


(tick applicable)

beta

gamma

2.3

Radiation Monitoring Requirements Isotope Decay Level:

Personal Dose Meter Area Monitoring

(tick the appropriate response) Yes No 2.4 2.5 2.6 2.7 2.8 2.9 Approved Method Statement Provided Supervision present at all times Is the correct P.P.E supplied and its use enforced Task Safety Analysis & employee briefing provided Physical barriers provided at works location Lighting above 100 LUX

Remarks

2.10 Safe access / egress provided 2.11 Adjacent operations affected 2.12 Equipment to be used in good condition and certified 2.13 Warning / Information signage provided 2.14 Is this P.T.W in conjunction with another P.T.W (specify) 2.15 Pre-commencement testing i.e. Isolation 2.16 Section 3. Attachments (Method Statements, Risk Assessments, Drawings, Certificates...etc) List all documents attached to this P.T.W:

ARCHIRODON GROUP NV Integrated Management System

Health, Safety & Environment (HSE) Rev. Issued For General Use Reference No. HSE-PRO-06-F02 Serial No. Page 2 of 2 Permit No:

FORM Radiography Permit To Work

0.0

Section 4. 4.1 4.2 4.3 4.4 4.5

Permit Management

This Permit is valid only when Sections 1-3 and 5 are complete. The original Permit shall be displayed at the work place and shall at all times remain under the responsibility of the Permit Holder. A separate copy of the completed Permit at both the approval and closure stages shall be given to the Permit Authority, the HSE Department and the Employer if required. Any adverse change in circumstances shall cause this Permit to become immediately invalid. In this case, the Permit Holder shall cease the work, withdraw the workforce and report to the Permit Authority. This Permit is issued for the task specified within this PTW only and is valid only between the times specified in section 1 of this document.

Section 5. 5.1

Permit Approval Name Signature Name NAME / SURNAME NAME / SURNAME Permit Holder HSE Department Permit Authority

I the permit holder shall abide to the control measures mentioned within this P.T.W and attachments.

5.2

HSE Review Signature The Permit Authority, I am satisfied that all foreseeable control measures to avoid an accident are in place prior to me authorizing this permit. Permit Closure Name Signature NAME / SURNAME

5.2

Section 6. 6. 6.a 6.b Name: Name:

Indicate either 6a or 6b. For 6b state the reason in the space provided [ [ ] The work covered by the Permit was completed at ] This Permit is Invalid Because: Permit Holder Permit Authority Time: HH:MM Date: DD/MM/YYYY

NAME / SURNAME NAME / SURNAME

Signature: Signature:

You might also like