DE-SHUTTERING WORK PERMIT Form # HSEQ - DSWP Rev 2.docx

1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company

2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:



Location, Grid Line & Floor / Level:


No of persons working :

Permit Validity:
Time (from): __________Hrs.
Time (To): __________Hrs.
Date:


3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Method statement and Risk assessment developed, approved and communicated? ☐ ☐ ☐
Emergency response procedure and rescue plan are developed & communicated? ☐ ☐ ☐

Engage competent Scaffold erector and Carpenters for the de-shuttering task? ☐ ☐ ☐
All nails shall be removed from formwork materials upon dismantling or at least it shall be bent with hammer to avoid pricks? ☐ ☐ ☐

Pre-start briefing shall be done on daily basis before starting the work in each shift? ☐ ☐ ☐
Protruding steels shall be protected by rebar cap or fabricated wood cap. Immediately relocate dismantled materials from the activity area? ☐ ☐ ☐

Ensure de-shuttering area is illuminated with task light? ☐ ☐ ☐
Do not leave any struck formwork materials hanging in concrete (i.e. plywood, wood). Peel off the duct tape used to cover the plywood gaps ☐ ☐ ☐

Do not throw form work materials from top to ground level? ☐ ☐ ☐
Do housekeeping every one hour. Stack the stripped off materials according to its size and type separately away from access routes and pedestrian walk ways ☐ ☐ ☐

Ensure two men handle each form work material to bring down safely and stack them safely? ☐ ☐ ☐
Ensure the availability and use of Safety Helmet, Hand gloves, clear eye protection, Safety Harness and ear plug. ☐ ☐ ☐

Ensure safety harness is hooked to the scaffold ledger above shoulder level while de-shuttering. ☐ ☐ ☐
Ensure Lifting plan implemented if any lifting activity for de-shuttering work. ☐ ☐ ☐

Ensure work platforms without openings and ensure proper access / egress. ☐ ☐ ☐
Restrict other unnecessary movements. Ensure de-shuttering area is barricaded with no entry warning signs? ☐ ☐ ☐

De-shuttering shall be done in same fashion as explained by form work designer and trained by respective section Engineer? ☐ ☐ ☐
Others( Specify) ☐ ☐ ☐

Dismantling of frames and support of formworks shall be from top to bottom provided with safe access & working platform? ☐ ☐ ☐
☐ ☐ ☐


4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I consider them competent to do it safely.
Initiator/Originator Name: Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity

Evaluator

1. DE-SHUTTERING WORK PERMIT
Page 1 of 2 Form # HSEQ-DSWP (Rev 2 - Mar 23)



1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company

2. Permit Issuance Details: (To be filled by initiator/originator)
THIS PERMIT IS ONLY FOR ONE SHIFT AND NOT EXTENDABLE
Description of Task:




Location, Grid Line &
Floor / Level:



No of persons working :

Permit Validity:

Time (from): __________Hrs.

Time (To): __________Hrs.

Date:


3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Method statement and Risk assessment
developed, approved and communicated? ☐ ☐ ☐
Emergency response procedure and
rescue plan are developed &
communicated?
☐ ☐ ☐
Engage competent Scaffold erector and
Carpenters for the de-shuttering task?
☐ ☐ ☐
All nails shall be removed from
formwork materials upon dismantling
or at least it shall be bent with hammer
to avoid pricks?
☐ ☐ ☐
Pre-start briefing shall be done on daily basis
before starting the work in each shift?
☐ ☐ ☐
Protruding steels shall be protected by
rebar cap or fabricated wood cap.
Immediately relocate dismantled
materials from the activity area?
☐ ☐ ☐
Ensure de-shuttering area is illuminated with task
light?
☐ ☐ ☐
Do not leave any struck formwork
materials hanging in concrete (i.e.
plywood, wood). Peel off the duct tape
used to cover the plywood gaps
☐ ☐ ☐
Do not throw form work materials from top to
ground level?
☐ ☐ ☐
Do housekeeping every one hour.
Stack the stripped off materials
according to its size and type
separately away from access routes
and pedestrian walk ways
☐ ☐ ☐
Ensure two men handle each form work material
to bring down safely and stack them safely?
☐ ☐ ☐
Ensure the availability and use of
Safety Helmet, Hand gloves, clear eye
protection, Safety Harness and ear
plug.
☐ ☐ ☐
Ensure safety harness is hooked to the scaffold
ledger above shoulder level while de-shuttering.
☐ ☐ ☐
Ensure Lifting plan implemented if any
lifting activity for de-shuttering work.
☐ ☐ ☐
Ensure work platforms without openings and
ensure proper access / egress.
☐ ☐ ☐
Restrict other unnecessary
movements. Ensure de-shuttering area
☐ ☐ ☐

2. DE-SHUTTERING WORK PERMIT
Page 2 of 2 Form # HSEQ-DSWP (Rev 2 - Mar 23)
is barricaded with no entry warning
signs?
De-shuttering shall be done in same fashion as
explained by form work designer and trained by
respective section Engineer?
☐ ☐ ☐
Others( Specify)
☐ ☐ ☐
Dismantling of frames and support of formworks
shall be from top to bottom provided with safe
access & working platform?
☐ ☐ ☐ ☐ ☐ ☐

4. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives,
and I consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Date /Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE & QC
Team):
Designation:
Signature: Date /Time
Comments (if any):




5. Authorization (PM/CM):
Name: Designation:
Signature: Date /Time:

6. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time