Confined Space Entry Permit - Record

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location of works
  Address

• Personnel

• Date and Time of entry

  Date

• Entry/Access Permit Number

• Confined Space Location
  Address

• Description of Works

• Manhole No:

• Site Photo

  Media

Entry Personnel

• Entry Personnel

Person

• Name

  Sign

• Expiry Date of Confined Space Entry (CSE) Ticket

Surface Personnel

• Surface Personnel

Person

• Name

  Sign

• Expiry Date of Confined Space Entry (CSE) Ticket

Confined space to be isolated from

• Water / Gas / Steam / Chemicals

• Auto fire extinguishing systems

• Mechanical / Electrical drives

• Hydraulic / Electric / Gas / Power

• Sludge/ Deposits / Wastes

• Locks and/or tags have been affixed to isolation points

  Yes

  No

  N/A

• Required Isolations to be checked by

  Sign

• Are any hot works to be performed in the confined space?

  Yes

  No

  N/A

• Hot work permit number

• Will the Hot Works release toxic vapours?

  Yes

  No

  N/A

• Describe control measures to be implemented to enable the Hot Works to be performed safely

• Has the area been cleared of all readily combustible materials within 15 metres?

  Yes

  No

  N/A

• Have all drains within 15m been covered with a wet fireproof blanket?

  Yes

  No

  N/A

• Appropriate number of fire extinguishers on site near source of ignition?

  Yes

  No

  N/A

• List types of extinguishers

• All power leads clear of pipelines?

  Yes

  No

  N/A

• All power leads clear of access way?

  Yes

  No

  N/A

• Is extra ventilation required?

  Yes

  No

  N/A

• Type & Location

• Is a water hose available & tested on site?

  Yes

  No

  N/A

• Has continuous communication been tested and established prior to entry?

  Yes

  No

  N/A

• Radio

• Lifeline

• Visual

• Speaking

• Other

• Communication

Equipment

• Relevant items of Personal Protective Equipment (PPE) and other equipment required by persons entering the Confined Space

• Foot protection

• Hearing protection

• High visibility

• Safety helmet

• Eye protection

• Face protection

• Hand protection

• Breathing protection

• Protective clothing

• Fall Arrest / Harness

• Other

• Personal Protective Equipment

PPE Equipment

Atmospheric testing - record readings prior to entry

• Recommended Levels:
  Oxygen between 19.5% to 23.5%
  Explosive Gas < 5% LEL
  Hydrogen Sulphide < 10ppm
  Carbon Monoxide < 30ppm

• Oxygen (%)

• Explosive Gas - Lower explosive limit (LEL%)

• Hydrogen sulphide (ppm)

• Carbon monoxide concentrations (ppm)

• Other Gases Tested

• Atmospheric Testing

Element

• Reading

• Is continuous monitoring required for the duration of the entry into the space?

  Yes

  No

  N/A

• Name of entry personnel

• Date & Time In

  Date

• Date & Time Out

  Date

• All persons have left the confined space. No further entries permitted without new permit.

  Yes

  No

  N/A

• All equipment has been removed from site?

  Yes

  No

  N/A

• All isolations have been restored?

  Yes

  No

  N/A

• Sign off Authorising CSE Name & Signature

  Sign