Confined Space Entry Permit

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

  Select
• Location
  Address

• Confined Space ID:

• Location of Confined Space

• Permit Issued by:

  Select

• Description of work to be undertaken:

Risk Assessment

• Has a risk assessment been completed?

  Yes

  No

  N/A

Isolation of the confined space - isolated from:

• Electrical /mechanical drives

  Yes

  No

  N/A

• Hydraulic/electrical/gas/power

  Yes

  No

  N/A

• Sludge/deposits/wastes

  Yes

  No

  N/A

• Tags/locks have been fitted by each person in the space

  Yes

  No

  N/A

• Isolation point identified

  Yes

  No

  N/A

Atmospheric Testing: Pre-operational checks of the instruments have been carried out. Continuous monitoring of the atmosphere is required

• Oxygen level - %

• Flammable gases/vapor - % LEL

• Hydrogen sulphide - ppm

• Carbon monoxide - ppm

• Time of testing

  Date

Conditions of entry

• With breathing apparatus

  Yes

  No

  N/A

• Without respiratory protection

  Yes

  No

  N/A

• With escape unit

  Yes

  No

  N/A

Hot Work

• Area clear of all combustibles

  Yes

  No

  N/A

• Hot work permit completed

  Yes

  No

  N/A

• Hot work safe to proceed

  Safe

  At Risk

  N/A

PPE

• Select PPE to be used

  Select

Other Precautions

• Barricades

  Yes

  No

  N/A

• Warning signs

  Yes

  No

  N/A

• Trained personnel

  Yes

  No

  N/A

• Stand by personnel

  Yes

  No

  N/A

Ventilation

• Natural

  Yes

  No

  N/A

• Fan/blower

  Yes

  No

  N/A

• Manhole cover up or down stream

  Yes

  No

  N/A

Emergency response

• Emergency response call "000'

Authority to enter: The control measures and precautions appropriate for the safety and execution of the work in the confined space have been implemented and the persons required to work in the confined space have been advised of and understand the requirements of this 'Entry Permit".

• Person in control

  Sign

• This entry permit is valid until:

  Date

• Persons required to enter the Confined Space:

  Select

Withdrawal of Entry Permit

• ,The work has been completed

  Yes

  No

  N/A

• All personnel and equipment have been accounted for

  Yes

  No

  N/A

• The space if fit for use

  Yes

  No

  N/A

• The space is not fit for use: (include note)

  Yes

  No

  N/A

• The access cover has been replaced and or the space has beed locked

  Yes

  No

  N/A

• Person in control of Entry Permit

  Sign

• Notes if required