Authorisation to Work Scheme

Contractors details

Contractor's Company Name *

Street Address *

City *

County *

ZIP / Postal Code *

Country *

Date of Arrival *

Time of Arrival *

Hours

Minutes

Contractor's Office Telephone Number

Supervisor's name and mobile number to the contact on site *

Work Activity and Controls

State type of work being undertaken *

State location of the work *

What are the hazards presented by the work and who may be exposed to the activities of the contactor? *

State how you intend to control the risk to people from proposed work activity?

Are you a contractor

Have you provided a relevant risk assessment and method statement for the work activity ? If not, why not?

Please provide a reason of why you haven't provided a relevant risk assessment and method statement

Premises Control Measures

Asbestos

Have you been provided with, and understood the Asbestos Management Register and associated asbestos survey(s)? *

Is your work intrusive or interfere with the fabric of the building? *

If "YES" has a Permit to undertake Building Work been submitted to the Property Service and approved *

Confirm contractors have current Asbestos Awareness training *

Fire

Have you been provided with the premises emergency arrangement i.e. location of primary and secondary escape routes, muster point and evacuation procedures? *

Will you be carrying out any "Hot Works"? *

If "YES", ensure a Hot Works Permit is in place and that ALL hot work must cease at least ONE HOUR before the end of the working day and a "Fire Watch" is carried out *

Workplace Transport

Have you been provided with any transport movement (including deliveries) and parking restrictions? *

Are Banksmen/Reversing Assistants required? *

Security and Safeguarding

Are there any areas of the building where contractors are prohibited or require escorts? *

Working Times

Contractor are restricted to the following working hours unless agreed by the Premises Responsible Person

Start Time *

Hours

Minutes

End Time *

Hours

Minutes

Site Specific Constraints and Restrictions

Please State *

Shared Responsibility and Agreed Control Measures

Responsible Person to Complete

Print Name *

Signature *

Date *

Contractor Person to Complete

Print Name *

Signature *

Date *