2025 GAHFM Technical Education Conference-example 2 Medical_Gas_Permit_to_Work_Form_Fillable

example 2 Medical_Gas_Permit_to_Work_Form_Fillable_2Page

Pdf Summary

This document outlines a Permit to Work procedure for the maintenance or repair of a medical gas system, specifically covering gases such as oxygen, air, vacuum, nitrous oxide, carbon dioxide, nitrogen, or others. The permit includes essential general information such as permit number, issue and expiry date/time, location, reason for work (preventive maintenance, repair, emergency, upgrade), technician details, certifications, company, and authorizing personnel.<br /><br />Key sections address isolation and safety verification, ensuring control/zone valves are located, identified, closed, tagged “DO NOT USE,” and lockout/tagout (LOTO) procedures applied with clear documentation of system pressure before work. Staff notification and clearance of affected areas are mandated. Work controls emphasize use of oxygen-clean tools, absence of ignition sources or hydrocarbons, proper personal protective equipment (PPE), fire watch assignment for hot work like brazing, nitrogen purging during brazing, and adequate ventilation. Alternate gas supply sources such as portable cylinders or manifolds must be available if necessary.<br /><br />Post-repair testing and verification requires visual inspection of labels/indexing, pressure, flow, and leak tests compliant with NFPA 99 5.1.12, gas purity confirmation via analyzers, purging with dry nitrogen if the system was opened, alarm system checks, and final sign-off by a certified ASSE 6030 verifier. Authorization and handover involves responsible persons including clinical or respiratory therapy representatives.<br /><br />Completion steps require confirmation of finished work, LOTO removal, reopening zone valves, notifying affected areas, and maintaining records in the maintenance log. The permit must remain posted onsite until the system is fully returned to service, in compliance with NFPA 99 5.1.14.<br /><br />Additionally, a Med Gas Backfeed Map details oxygen and medical air cylinders feeding specific floors and wings within a facility, showing isolation valves that control floors 4, 5, and 6 from the 3rd floor. This map aids in system isolation during maintenance.

Keywords

Permit to Work

medical gas system

oxygen

nitrous oxide

lockout/tagout

oxygen-clean tools

NFPA 99 compliance

gas purity testing

ASSE 6030 verifier

Med Gas Backfeed Map