Title Page
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Document No.
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Client / Site
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Prepared by
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Conducted on
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Location
Details of Work
Details of Work to be Undertaken
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Date of Entry
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Work Order Number
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Site where space is to be Entered
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Location of Space
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Details of Work to be Undertaken
Confined Space Assessment
Confined Space Assessment
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Space has previously been designated as a Confined Space? ---If in Doubt select NO---
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Is the Space NOT designed for continual Worker occupancy?
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The Confined Space assessment indicates that the space is NOT a Confined space, work may proceed without a confined space permit provided the following requirements are met
Approval from line supervisor who has the appropriate knowledge of the space. -
Is the space designed or intended to be at normal atmospheric pressure while any person is in the space?
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The Confined Space assessment indicates that the space is NOT a Confined space, work may proceed without a confined space permit provided the following requirements are met
Approval from line supervisor who has the appropriate knowledge of the space. -
Is the Space - Enclosed or Partially Enclosed?
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The Confined Space assessment indicates that the space is NOT a Confined space, work may proceed without a confined space permit provided the following requirements are met
Approval from line supervisor who has the appropriate knowledge of the space. -
AND within the Space is there a risk of one or more of the following? Select all that Apply
- Oxygen concentration outside of the SAFE Oxygen range?
- A concentration of flammable airborne contaminant that may cause injury from fire or explosion?
- Engulfment in a free flowing solid or rising level of liquid that may cause suffocation or drowning?
- A concentration of of airborne contaminant that may cause impairment, loss of consciousness or Asphyxiation?
- None of the Above
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The Space has been assess as being a "Confined Space" and the remaining sections MUST be completed prior to any work commencing within the Confined Space.
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The Confined Space assessment indicates that the space is NOT a Confined space, work may proceed without a confined space permit provided the following requirements are met
Approval from line supervisor who has the appropriate knowledge of the space. -
Name
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Select date
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Name of Person who completed the Assessment
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Date of Assessment
Risk Management
To be completed if area designated Confined Space
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Confirm area is a Confined Space?
Risk Management Plan (Permit Recipient to complete if Space is deemed CONFINED SPACE
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JSEA/ SWMS developed
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High Risk Work rescue plan developed?
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Isolation Instruction Developed
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Other High Risk work permit required?
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Name of Standby Person
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Name of Rescue Person
Risk Controls
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Signs & Barricades
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Life & Rescue Lines
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Traffic Control
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Tripod / Davit
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Ventilation Equipment
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Self Contained Breathing Apparatus
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Lighting ( with portable RCD Protection)
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2 way Communication Equipment (eg Radio's, Sat Phone etc)
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Other ( enter details as required)
Pre- Entry Activities
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Isolation's Complete
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Drain Down Complete?
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Purging Required?
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Method used to conduct Purging?
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On going Ventilation required?
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Method of Ventilation used
Pre- Entry Atmospheric Testing
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Atmospheric Testing equipment is in Date & Compliant
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Atmospheric Testing device recorded as Non Compliant !!! No entry into Confined Space until testing done with compliant Meter.
Create an action. You have the option to assign the action to a user within your organization account and set a priority and due date. The assignee will receive a notification. Tap the Paperclip Symbol -
Bump Test Successful?
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Remember to change the Atmospheric testing equipment from Real Time to Data Log to get Peak readings from inside the space.
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Atmospheric Test - Oxygen - Top of Space
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Atmospheric Test - Oxygen -Middle of Space
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Atmospheric Test - Oxygen - Bottom of Space
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Warning! Oxygen level is close to Upper limit and may require additional Control Measures
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Warning! Oxygen level is close to Lower limit and may require additional Control Meaures
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Danger - Oxygen levels are Outside Safe Range !
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Atmospheric Test - Combustibles - Top of Space
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Atmospheric Test - Combustibles - Middle of Space
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Atmospheric Test - Combustibles - Bottom of Space
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Danger! Combustible readings are higher than permissible values!
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Warning! Combustible readings are close to upper Limit and may require additional Control Measures
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Atmospheric Test - Hydrogen Sulphide - Top of Space
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Atmospheric Test - Hydrogen Sulphide - Middle of Space
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Atmospheric Test - Hydrogen Sulphide - Bottom of Space
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Warning! Hydrogen Sulphide Levels are close to Upper Limit and may require additional Control Measures
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Danger! Hydrogen Sulphide Levels are higher than Permissible Values
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Atmospheric Test - Carbon Monoxide - Top of Space
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Atmospheric Test - Carbon Monoxide - Middle of Space
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Atmospheric Test - Carbon Monoxide - Bottom of Space
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Warning! Carbon Monoxide Vales are close to Upper Limit and mat require additional Control Measures
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Danger! Carbon Monoxide Levels are higher than Permissible Values
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For other Contaminants not listed, specific monitoring devices & Pre-work planning will be required to ensure safe entry.
ALL WORKERS ARE PROHIBITED FROM ENTERING A CONFINED SPACE WHERE A SAFE ATMOSPHERE IS UNABLE TO BE ACHIEVED
The atmosphere in a confined space must be continuously monitored whilst workers are in the space.
Entry Authorisation ( Recipient To Complete)
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The Confined Space described in this permit is safe to enter using the processes, control measures and precautions listed above and detailed on the supporting JSEA / SWMS. Workers required to work in the Confined Space have been advised of, and understand, the requirements and risks of the work, including the requirements detailed in the supporting High Risk Rescue Plan.
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Permit Recipient Name & Signature
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Contact Number
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SIgnature Time & Date
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Period of Time that the permit is authorised (Start Time) Max 24 Hours
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Period of Time that the permit is authorised (End Time)
Entry Activity Log In / Out (Entrants To Complete)
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I the undersigned hereby acknowledge that I understand the processes, Control Measures and precautions to be observed for this Confined Space entry. I will comply with these requirements at all times and immediately report any new or unforeseen hazards that present a risk to entry.
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Sign In / Sign Out Records
Workers Names
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Workers Names
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Enter Time In Confined Space
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Enter Time Out of Confined Space
Permit Close
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I confirm that all work associated with this permit is Complete, all personnel named above have exited the space, all tools and Equipment have been removed from the space and that all plant and the confined space have been reinstated correctly and safely
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Name of permit recipient
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Sign off Time and Date
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End of Assessment, Click Complete Audit
