LCN Permit to Work Form

PERMIT TO WORK (LABORATORIES AND WORKSHOPS) (LCN_GN5_May2016)

Permit Number: Please complete in conjunction with Allocated by issuing Person Format LCN (lab number)_000 associated LCN Guidance document

(A) PERMIT ISSUE DETAILS (to be completed by Lab Manager or nominated responsible person)

1. Location of work / equipment area Building:

Area PI/Responsible Person:

Room/Laboratory/Workshop:

2. Work to be done Title of work:

Description of work: Risk Assessment Method Statement (RAMS) Reference:

3. Timescale of work Date and time of required access:

Date and time of completion:

4. Services Affected (Inform UCL Estates None Electricity Piped gas Steam Water RO Water helpdesk Ext 30000) Other (specify): Note Estates Permit to Work Number (if applicable) and valid Date/Time:

5. Hazards present in area / equipment Description Precautions

Biological (Hazard Group /Containment Level, GMO)

Chemical (Hazardous)

Non-Ionising Radiation ( EMF, UV)

LASER (Class, Power)

Ionising Radiation (Open/Sealed sources)

Electrical (HV, cabling)

Compressed gases & cryogenic liquids

Working at Height

Environment (internal/external, wet, lighting confined space)

Pressurised Equipment

Hazardous equipment

Other Hazards

LCN_GN5_Permit to Work Labs-Workshops May 2016 (v1) Dr Paul Cassell

(B) EQUIPMENT DECLARATION OF CONTAMINATION CERTIFICATE

Please indicate below whether any item of equipment removed for repair or disposal will require a completed DoC Certificate

NEVER REQUIRED YES NO ALWAYS REQUIRED YES NO PLEASE SPECIFY: SOMETIMES REQUIRED

I confirm that the above work can be carried out safely and that I have informed all local staff whose work may be affected that where necessary their work is suspended in this area. I have provided laboratory/workshop induction.

Lab Manager (or responsible person) signature: Print Name:

Date: Time:

(( D) PERMIT RECEIPT (declaration must be signed by operative or contractor))

I/We have read and understood the above precautions required and the conditions of validity. Should I/we at any time not be satisfied that the work / equipment area is sufficiently cleared and the area appears unsafe, I/we will raise the concerns with the respective lab manager and/or Safety Officer before commencing work in the area Operative / contractor signature: Print Name:

Date: Time: Comments:

(E) WORK COMPLETION (declaration must be signed by operative or contractor)

The work described above has been completed / is incomplete* (delete as appropriate) All personnel, materials and equipment have been removed and area left clean and tidy The work area* and/or equipment* has been left in safe condition (* delete as necessary)

Operative / contractor signature: Print Name:

Date: Time:

(F) WORK ACCEPTANCE AND CESSATION OF PERMIT TO WORK

I accept the work has been completed and the area / equipment can now be returned to normal use. The permit has ceased to be valid

Lab Manager (or area responsible person) signature: Print Name:

Date: Time:

LCN_GN5_Permit to Work Labs-Workshops May 2016 (v1) Dr Paul Cassell