Confined Space Entry Permit

• Site conducted

• Permit Issue Date & Time

  Date

• Permit Expiry Date & Time

  Date

• Prepared by

• Description of Location

• Department Name

• Street Address
  Address

• Purpose of Entry

• Supervisor(s) in Charge of Crew

• Work to be Performed in Space

• Standby Personnel/Attendant

• Name(s) of Authorized Entrants

• Has the surrounding area been surveyed and found free of hazardous atmospheric hazards?

  Yes

  No

• Is the work area likely to remain free of any dangerous air contaminants?

  Yes

  No

• Have all personnel in the designated work area been briefed on paper work procedure and the location of communications and who to contact in an emergency?

  Yes

  No

• Do all areas of work and machinery have some type of lockout and tagout installed in the proper place?

  Yes

  No

• Will testing be done continuously while the space is occupied?

  Yes

  No

• Is all safety equipment (i.e. gas monitor) to be used in good condition an in proper working order?

  Yes

  No

• NOTICE: IF ANY OF THE ABOVE QUESTIONS ARE ANSWERED “NO”, CONTACT YOUR IMMEDIATE SUPERVISOR!

Entry, Standby, and Backup Persons

• Successfully completed required training?

  Yes

  No

• Is this training current?

  Yes

  No

Training: Are you (personnel) trained in

• First Aid, CPR?

  Yes

  No

• Confined Space Entry?

  Yes

  No

Did you (personnel)

• Receive a pre-entry briefing on the plan to follow while in a confined space?

  Yes

  No

• Receive a pre-entry briefing on identifying and using PPE in confined space?

  Yes

  No

• Receive a pre-entry briefing on emergency rescue procedures?

  Yes

  No

Has/Have the

• Testing equipment been calibrated properly?

  Yes

  No

• Confined space/area been tested by a qualified person?

  Yes

  No

• The confined space/area been assessed for:<br>- Atmospheric contaminants, including gases, vapours, fumes, dusts or mists?<br>- Oxygen level been tested to be between 19.5 – 23%?<br>- Tested for the accumulation of flammable, combustible or explosive agents?

  Yes

  No

• Potential hazards of conductive heat transfer been evaluated?

  Yes

  No

• Any Hot Work considerations been assessed:<br>- Have Hot Work signs been posted?<br>- Has a permit been approved and posted?<br>- Has the Hot Work procedure been communicated?

  Yes

  No

• Space Preparation Methods

  Select Drained Flushed Steamed Barricaded Inerted Purged Ventilated Other

  • Drained
  • Flushed
  • Steamed
  • Barricaded
  • Inerted
  • Purged
  • Ventilated
  • Other

• What method was used?

Rescue System:

• - Is all the rescue equipment identified on the plan available and in good working condition?<br>- Have all the workers received training on the equipment to be utilized during an emergency?

  Yes

  No

• Safety Equipment (Select all appropriate equipment to be used)

  Select Cellular Radio Gas monitor Eye Wash First Aid Kit Foot Protection GFCI Hand Protection Hard Hat Harness Hoisting Equipment Intrinsically Safe Equipment Non-Spark Tools Powered Communications Protective Clothing Radio Respiratory Protection Retrieval/Life Line Safety Harness and Lifelines for Entry and Standby Persons SCBA’s for entry and standby persons Statically Grounded Traffic Control Tripod/Winch Wristlets

  • Cellular Radio
  • Gas monitor
  • Eye Wash
  • First Aid Kit
  • Foot Protection
  • GFCI
  • Hand Protection
  • Hard Hat
  • Harness
  • Hoisting Equipment
  • Intrinsically Safe Equipment
  • Non-Spark Tools
  • Powered Communications
  • Protective Clothing
  • Radio
  • Respiratory Protection
  • Retrieval/Life Line
  • Safety Harness and Lifelines for Entry and Standby Persons
  • SCBA’s for entry and standby persons
  • Statically Grounded
  • Traffic Control
  • Tripod/Winch
  • Wristlets

Periodic Atmospheric Tests

Oxygen

• %

• Time

  Date
Explosive

• %

• Time

  Date
Toxic

• %

• Time

  Date

Permit Prepared By

• Print Name

• Signature

  Sign

Approved By

• Print Name

• Signature

  Sign

Additional Employees/Supervisors Present

• Print Name

• Signature

  Sign

• Add media

  Media