DIVE SUPERVISOR (TO BE COMPLETED WITH PERMIT TO WORK FORM)
Date:	Permit to Work form Number:
Exact Harbour Location (within Port Limits):
If Darwin Port or the Harbourmaster identifies conflicting operations and there is a likelihood of a safety risk you will be contacted.
DO YOU REQUIRE A LOCAL NOTICE TO MARINERS? Choose an item.
Dive Organisation and Vessel name: Enter Name Enter Vessel Name
Dive Organisation Supervisor name: Enter Name	Contact Number: Enter Number
Name of Divers: Enter Name, Enter Name, Enter Name
Description of dive works:
Description of all equipment to be used:
Does the Organisation carrying out the business understand the duties (WH&S Regulations Part 4.8) that are imposed on the person in charge?	Choose an item. Why:
Permit Valid from: Enter Date	Permit Time from: Enter Time
Permit Valid to: Enter Date	Permit Time to: Enter Time
The following questions are derived from the WH&S Regulations. Please answer all questions
Has the diver(s) been deemed medically fit, been trained and holds a qualification?	YES ☐
All dive equipment is serviceable, fit for purpose and in current certification?	YES ☐
Will a Dive Plan be completed?	YES ☐	NO ☐
Are all mandatory minimum control measures in place?	YES ☐
Will Dive flags and/or surface markers be deployed?	YES ☐	NO ☐
Have weather conditions been taken into account?	YES ☐	NO ☐
Vessel/Supervisor will monitor VHF CH10 and CH16	YES ☐
Will all First Aid requirements be met?	YES ☐	NO ☐
Does the Dive Supervisor intend to provide notification to Harbour Control Tower on set up and completion of diving?	YES ☐
NOTE: Where you have answered No please explain why? Enter Detail
By submitting this form the Supervisor is agreeing that information provided is true and correct and to provide the Darwin Port assurance that the company the Supervisor represents has a satisfactory documented safe system of works in place and all qualifications, permits and licences are current.
Printed Name:	Signature:
NOTE# Where the Harbourmaster identifies conflicting operations and there is a likelihood of a safety risk to persons, you will be contacted on the number provided.
EMAIL TO: ntm@nt.gov.au (Harbourmaster for Notice to Mariners)	EMAIL TO: HarbourControl@darwinport.com.au

Harbour Control USE ONLY	Notice complete ☐	Cargo advised ☐	Wharf Services advised ☐