Download PTW Request Form

PTW REQUEST FORM
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QCOPS-BX00-HSS-FRM-000023_0
All Upstream Operations work must be planned, scheduled and appear on the Upstream Operations 2 week plan (with the exception
of break-in work).
This form is to be attached to a Work Pack containing the required information and provided to the QGC Permit Issuer a minimum of
72 hours before the work is due to commence, with relevant Endorsing Authority approval where required.
Work will only be approved to proceed if it is on the 2 week plan and the PTW Request is on time & accurate for the scope of work.
Break-in work must have Area Operations Superintendent or Site Safety Manager Approval.
This PTW request form is not mandated for break in work. (Liaise directly with the Permit Issuer for guidance.)
Section 1: To be completed by the Permit Holder (or appropriately skilled company representative)
Work Order Number:
QGC Permit Office Location:
Date Request Submitted: ____/____/____
Specific Work Location:
Land Access Permission Required:
Field/Facility:
 N/A
 Yes If yes provide evidence
Expected Work Start Date: ______/______/______
Expected Duration: Days:_____ or
Hours if less than 1 day: ______
PTW Request Form completed by name:
Phone:
QGC Asset Holder/Project Manager name:
Phone:
QGC Certified Permit Holder name:
Phone:
Permit Holder Supervisor’s name:
Phone:
Scope of Work (be specific):
Proposed Tools and Equipment:
Identify specific work activities applicable to the proposed work
scope (tick the box/boxes)
Corresponding information required and provided with Work Pack/PTW Submission (tick boxes to
identify documents attached with this application)
Isolation:  Mech.  Valve Inst.  LV  HV
 Isolation Certificated to be completed by PH if PH is conducting the isolation
 Protective Systems Isolation (LO/LC valves, inhibits, overrides)
 Protective Systems Isolation Certificate to be completed by PH if PH is conducting the isolation
 Extra Low Voltage in hazardous area
 Only to be undertaken by QGC authorized personnel
 Low Voltage Electrical Work
 LV Access Certificate Only to be undertaken by QGC authorized personnel (Endorsing
Authority requirements as identified on certificate)
High Voltage Electrical Access
(When the work activity requires HV switching, the Plant Permit
Issuer will forward this application to the HV Permit Issuer and
the 2 PI’s will coordinate the work activities.)
Completion of documentation below is to be coordinated by the High Voltage Permit Issuer
 Authorized HV Recipient Name:______________________
 HV Access Certificate
 HV Switching Sheet
 HV Single line diagrams
 Authorized HV Recipient
Confined Space Entry
 Confined Space Risk Assessment
 Confined Space Certificate (Endorsing Authority is always required)
 Task Rescue Plan (Developed & Approved by persons trained and competent in Task Recue)
Excavation
 Excavation Certificate (Endorsing Authority requirements as identified on certificate)
 Documentation identified as “required” on Excavation Certificate
Lifting
 Lifting certificate (Endorsing Authority required for all critical lifts)
 Simple Lift plan
Hot Work:  Potential Ignition
Work at heights >2m
Positive Ignition
 Hot Work Certificate required for positive ignition source (Endorsing Authority requirements as
identified on certificate)
 Work at Heights Certificate (Endorsing Authority requirements as identified on certificate)
 Task Rescue Plan(Developed & Approved by persons trained and competent in Task Recue)
 SWMS/s attached (Approved (signed) by the Permit Holder’s Supervisor) and SWMS title/s (and document control numbers where applicable) listed below:
 Evidence of Permit Holder Work Party QGC general and site specific inductions and certifications, licenses, qualifications for scope of work must be available to
produce during work activity (tick to confirm)
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PTW REQUEST FORM
QCOPS-BX00-HSS-FRM-000023_0
Section 2: To be completed by the Permit Issuer
Name of Permit Issuer reviewing request:
Is the work timing, PTW request form and associated documents adequate for the application to progress?  Yes
 No
Notes: e.g. provide reason/s below and send back to Permit Holder or provide information to forward on to HV Permit Issuer.
(If the work activity requires HV switching, the Plant Permit Issuer must forward this application to the HV Permit Issuer and the 2 PI’s will coordinate the work.)
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