KD-HTM-MG-003
Medical Gas Pipeline Systems Permit to Work
The medical gas permit to work: the gas, the terminal units and the department affected, the Designated Medical or Nursing Officer's agreement and the cylinder cover before any valve is closed, the isolation and its locks, the precautions for the work, the Competent Person's tests on completion, the Quality Controller's release, and the return to clinical use.
3 pages · 133 fillable fields · works in Adobe Reader, Preview, Chrome, or on a phone — or complete it online in your browser and download the finished document.
Page 1 of 3 — click to enlarge
Read all 3 pages first — watermarked sample, no email Before you submit: the checklist
Statutory basis, cited on the form
- MHSWR 1999 reg 3
- CDM 2015 regs 13 and 15
Guidance and standards relied on
These are not law. HSE guidance carries no statutory force in itself, British Standards and NASC technical guidance are industry documents, and the Joint Code of Practice is an insurers' code. They are what the document is built to — and where a court would look for the standard of the reasonable contractor.
What it is not
It is not a completed document and it is not health and safety advice. You must adapt it to your site and have a competent person complete and sign it off. See why we don't say "compliant".
Format
AcroForm fillable PDF. Every field has a tooltip. Tab order follows the reading order. Works on desktop and mobile, in Adobe and non-Adobe readers.
This revision was prepared against legislation current at 10 August 2026. Revision A0. Check kubitdocs.com/revisions for the current revision before use.
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