2025 GAHFM Technical Education Conference-example 1 Medical_Gas_Permit_to_Work_Form_Fillable

example 1 Medical_Gas_Permit_to_Work_Form_Fillable_2Page

Pdf Summary

This document is a Permit to Work form for maintenance or repair of medical gas systems, including gases such as oxygen, air, vacuum, nitrous oxide (N2O), carbon dioxide (CO2), nitrogen, or others. The permit outlines procedures to ensure safe and compliant work execution in healthcare facilities.

Key sections include:

1. <strong>General Information:</strong> Captures permit number, issue date/time, expiration, location, reason for work (preventive maintenance, repair, emergency, or upgrade), gas type involved, technician details with certification, contractor company, and authorization.

2. <strong>Isolation and Safety Verification:</strong> Requires locating and identifying control or zone valves, notifying staff and clearing affected areas, closing and tagging valves with 'DO NOT USE', applying lockout/tagout (LOTO) with date/time records, verifying system pressure before work, confirming alternate gas supply availability, and posting “Work in Progress” signage. It also mandates use of oxygen-clean tools per CGA G-4.1, ensuring area free from ignition sources or hydrocarbons, wearing appropriate PPE (gloves, eye protection, face shield), assigning fire watch if hot work (brazing) is involved, using nitrogen purge during brazing, and ensuring proper ventilation.

3. <strong>Work Controls and Precautions:</strong> Details all measures ensuring safe work conditions, emphasizing compliance with fire and contamination prevention guidelines.

4. <strong>Post-Repair Testing and Verification:</strong> Includes visual inspection of labeling and indexing, pressure/flow/leak testing according to NFPA 99 5.1.12, gas purity confirmation via analyzer, purging with dry nitrogen if system opened, alarm system checks (master and area), and final verification and sign-off by an ASSE 6030 certified individual.

5. <strong>Authorization and Handover:</strong> Requires documentation of personnel who performed the work, responsible person, verifier (ASSE 6030), and clinical or respiratory therapy representative.

6. <strong>Permit Closeout:</strong> Encompasses confirmation that work is completed, testing verified, lockout/tagout removed, zone valves reopened as applicable, affected areas notified, and all records filed in the maintenance log. The permit must remain posted on-site until normal system service resumes, ensuring full compliance with NFPA 99 5.1.14 standards.

Overall, this permit system ensures that medical gas system maintenance is performed safely with comprehensive hazards control, proper notification, detailed documentation, and adherence to regulatory standards to protect staff and patients.

Keywords

Permit to Work

Medical Gas Systems

Oxygen

Nitrous Oxide

Isolation Procedures

Lockout/Tagout (LOTO)

Safety Verification

NFPA 99 Compliance

Post-Repair Testing

Personal Protective Equipment (PPE)