Fire Protection Impairment Notification Form

Permit ID *

This form is to be used to notify DIA of works being conducted on the fire protection system, to log & monitor precautions put in place and to ensure all isolations have been reinstated.

This information should be reported to DIA at least 48 hours in advance or as soon as practical prior to work starting and be signed off when protection is restored.

This form and other associated paperwork must be duly signed and returned to Electrical Maintenance Coordinator for filing and review.

Status

Application Date *

Project No. *

ADG Project Manager Email *

Part 1 – Application Details

Company Name *

Supervisor Name *

Supervisor Phone *

Applicant's Email Address *This email will be used to send the approval notification and the link to fill up the system restoration form.

Location or site name *

Address *

Impairment from date *

Impairment to date *

Please specify the impaired equipment *

Are you in control of any existing isolations? *

YesNo

Please provide details *

Part 2 - Location/ Description

List all Isolated Equipment *

Reason for Impairment *

Confirm Shift End Time *

Other Precautions

ARFFS MUST be notified prior to isolations and at de-isolation. (8920 4810)

Supervisor Signature *

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Date

Part 3 - DIA Assessment

DIA Authorised Person *

Position *

Email *

Total percentage isolated *Including this impairment what will the total terminal isolation percentage be. If over 10%, a Risk Assessment will be triggered.

Total isolations exceeding 10% *

YesNo

Upload Risk Assessment *

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Impairment request approved *

YesNoPending - Need More Information

Detail what further information you require *

Detail reason for non-approval *

Signature *

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Date *

Part 4 - System Restoration

All equipment has been reinstated and systems have been checked. Please complete this form to confirm de-isolation.

Restored by

Name *

Company *

System Restored Date and Time *

DIA Notified by

Name *

Phone *

Position *

Date and time DIA Notified *

Does the Terminal Main FIP require a program update? *

YesNo

When will this upgrade be completed? *

Part 5 - Drawings/ Block Plans

Were drawings amended? *

YesNo

When will these be issued? *

By Who? *

Part 6 - DIA Sign Off

Insurers

Do Insurers need to be notified? *

YesNo

Insurer Details *

CAPTCHA *

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