Unit Work Permit

Maintenance, Repair & General Operations

ℹ️ NOTE: Complete a Job Safety Analysis (JSA) before starting work. Additional permits may be required for hot work, confined space, LOTO, or excavation.

📋 Permit Information

District / Base *

Date *

Start Time *

Expected End Time *

Work Location *

Specific Area

Work Type *

Risk Level *

Work Description *

👥 Personnel

Permit Issuer *

Work Supervisor *

Workers Assigned (one per line)

📄 Additional Permits

Additional Permits Required? *

Related Permit Numbers

⚠️ Hazard Assessment

Check all hazards present:

Fall HazardPinch PointsRotating EquipmentOverhead HazardsChemical ExposureNoise HazardElectrical HazardPressure SystemsHot SurfacesSharp Edges

Other Hazards / Details

🛡️ Controls & Precautions

Area barricaded/roped off?

Warning signs posted?

Equipment de-energized?

Tools inspected?

Lifting plan required?

Lifting plan approved?

📝 Job Safety Analysis

JSA/THA Completed?

JSA reviewed with crew?

Stop Work Authority discussed?

🦺 Required PPE

Hard Hat

Safety Glasses

Face Shield

Hearing Protection

Safety Boots

Gloves

FR Clothing

Fall Protection

✍️ Authorization Signatures

Permit Issuer Signature *

Work Supervisor Signature *

AnthroSafe™ Field Driven Safety