Radiography Permit to Work

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

1.3

Issued to

Permit Holder 

 NAME / SURNAME 

1.4

Issued by

Permit Authority

 NAME / SURNAME 

1.5

Job Location:

1.6

Work Activity:

from

 HH:MM 

on date  DD/MM/YYYY 

to

 HH:MM 

on date  DD/MM/YYYY 

Company

Section 2. Required Controls 2.1

X-Ray Generator: Model:

Maximum Tube Voltage kV:

Radioactive Isotope 2.2

Isotope:

Type of radiation

alpha

beta

gamma

(tick applicable)

2.3

Radiation Monitoring Requirements

Film Badge

Personal Dose Meter Area Monitoring

(tick applicable)

Isotope Decay Level: (tick the appropriate response) Yes No 2.4

Approved Method Statement Provided

2.5

Supervision present at all times

2.6

Is the correct P.P.E supplied and its use enforced

2.7

Task Safety Analysis & employee briefing provided

2.8

Physical barriers provided at works location

2.9

Lighting above 100 LUX

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 (M ethod Statements, Statements, Risk Assess Assessments, Dr awin gs, Cer Cer ti fi cates...etc)  cates...etc) 

 List all documents attached to this P.T.W: P.T.W:

Remarks

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

FORM Radiography Permit To Work 

0.0

Permit No: Section 4.

Permit Management

4.1

This Permit is valid only when Sections 1 -3 and 5 are complete.

4.2

The original Permit shall be displayed at the work place and shall at all times remain under the responsibility of the Permit Holder.

4.3

A separate copy of the completed Permit at both the approval and closure stages shall b e given to the Permit Authority, the HSE Department and the Employer if required.

4.4

Any adverse change in circumstances shall cause this Permit to become immediately i nvalid. In this case, the Permit Holder shall cease the work, withdraw the workforce and report to the Permit Authority.

4.5

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

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

 NAME / SURNAME 

 Name Signature

 NAME / SURNAME 

 Name 5.2

HSE Review Signature

5.2

The Permit Authority, I am satisfied that all foreseeable control measures to avoid an accident are in place prior  to me authorizing this permit.

Section 6.

Signature

HSE Department

Permit Authority

Permit Closure

6.

Indicate either 6a or 6b. For 6b state the reason in t he space provided

6.a

[

] The work covered by the Permit was completed at

[

] This Permit is Invalid Because:

6.b

 NAME / SURNAME 

 Name

Permit Holder 

Time:

 HH:MM 

Date:

 DD/MM/YYYY 

 Name:

 NAME / SURNAME 

Signature:

Permit Holder 

 Name:

 NAME / SURNAME 

Signature:

Permit Authority