Title Page

  • Conducted on

  • Prepared by

  • Position

  • Contract

  • Location

Atmosphere, Engulfment, Ventilation and Fire:

  • 1. Has the atmosphere been tested and is it within the defined safe range?

  • 2. Are ventilation systems implemented effectively to ensure adequate ventilation, e.g. Dilution or Local Exhaust Ventilation (LEV)?

  • 3. Have ignition sources been eliminated where a flammable atmosphere exists?

  • 4. Have controls associated with engulfment been implemented effectively?

Plant and Equipment Testing:

  • 5. Is the gas monitor calibrated and bump tested prior to use?

  • 6. Is correct confined space entry equipment available and tested to the relevant standard, e.g. harnesses and rescue equipment?

Permit and Procedures:

  • 7. Has a risk assessment been completed and controls implemented effectively?

  • 8. Has an entry permit been issued for each confined space entry and controls implemented effectively?

People and Training:

  • 9. Are all employees involved in the confined space work suitably trained and assessed as competent?


  • 10. Are all energy sources controlled and locked out?

  • 11. Are all entry points to the identified confined space signposted and barricaded off to prevent unauthorised entry?

Standby Communication:

  • 12. Can the standby person (attendant) maintain continuous communication with employees working in the confined space?


  • 13. Are controls associated with other work party interactions implemented effectively? (e.g. other workers, plant and equipment)

Emergency Response:

  • 14. Is there a documented rescue and emergency plan available on site and are all work parties aware of the agreed process?

  • 15. Is rescue equipment set up or available on site?

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