Template

Work Clearance Form Template

by Morten Petersen, from the Community

20+

This work clearance form template helps teams plan and authorize daily tasks by documenting permit and work order details, site and station information, assigned personnel, and planned activities. It supports hazard identification for traffic exposure, electric shock, and working at heights, and prompts required controls such as PPE verification and area barricading with cones or tape. The form includes arrival briefings, acknowledgment of risks, and completion sign-offs with signatures from the station representative and contractor to confirm work done and site handover.

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With SafetyCulture you can

Digitize any process, procedure or policy

Eliminate mistakes made by paper-based processes

Create and share professional reports instantly

Confirm accountability and compliance with a digital log

About author

Community

This community page makes available free workplace checklists and templates created by other users within the SafetyCulture community. SafetyCulture has re-published this content and where possible, has credited the original author. SafetyCulture has not verified the accuracy, reliability or suitability of any community content. You agree that your use of any of this content is in accordance with SafetyCulture’s Terms and Conditions.

Template
Work Clearance Form (WCF)
A downloadable Work Clearance Form (WCF) to plan daily activities and control risks before starting work. The form covers site details, personnel, permits, planned tasks, and a structured hazard assessment aligned with JSA. Checklists include traffic exposure, electric shock, falls from height, confined spaces, work at heights with ladders and lifts, hot work, temporary traffic areas, and explosive zones. It guides selection of PPE, barricading, JSA references, and specialized tasks for fuel systems including pumps, terminals, POS/ATG equipment, piping, tanks, venting, product changes, leak testing, loading/unloading, and environmental protection near water. Includes arrival confirmation, discussion of hazards, and sign-offs from site and contractor representatives to verify completion.
by Morten Petersen, from the Community
Downloads: 20+
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Template
Working at Heights Permit Template
This working at heights permit template helps you authorize and control work at elevation. Capture issuer and recipient details, start and end times, location, and a clear scope of work. Verify a Safe Work Checklist or Work Planning Form, confirm rescue plans, and check training requirements. Include PPE and equipment checks for ladders, scaffolding, EWP, harnesses, lanyards, and communications. Assess conditions such as weather, traffic, power lines, and signage. Record completion or suspension and clear the work area.
by vic copling, from the Community
Downloads: 0
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Template
Work Permit and Task Safety Assessment
Use this comprehensive work permit and task safety assessment template to plan and authorize contractor activities before work begins. It guides pre-work briefings, site protocols, and verification of method statements and risk assessments. Check PPE, tooling and equipment, signage, lifting, and manual handling readiness. Cover specialist hazards including hot work, confined spaces, working at height, and electrical isolation, with clear controls and permits. Include environmental checks for waste, noise, and spill response, plus site access, progress updates, and end-of-day tidy inspections. Capture signatures for permission to start and completion records.
by Andy Pryer, from the Community
Downloads: 0
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Template
Hospital Permit To Work Template
This Permit To Work template helps hospitals authorize and control contractor and maintenance activities. It captures permit details, contractor and competent person information, work scope and location, and RAMS submission and approval. It links associated high risk permits including hot works, working at height, confined spaces, isolated and live equipment. The form includes approvals, declarations, signatures, and clear acceptance of responsibilities. It guides permit clearance and closure, and verifies completion, safety, and any fire stopping measures such as sleeves, collars, covers, and sealants. Security checks confirm permits returned and closed.
by Stephen Dawson, from the Community
Downloads: 10+
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Work Clearance Form Template

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Work Clearance Form (WCF)

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Work Clearance Form (WCF)

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