Confined Space Entry Permit - Record

Identification

Date and Time of entry

Entry/Access Permit Number

Confined Space Location

Description of Works

Manhole No:

Site Photo

Personnel

Entry Personnel
Entry Personnel
Name

Expiry Date of Confined Space Entry (CSE) Ticket

Surface Personnel
Surface Personnel
Name

Expiry Date of Confined Space Entry (CSE) Ticket

Isolation

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

Required Isolations to be checked by

Hot work

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

Hot work permit number

Will the Hot Works release toxic vapours?

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?

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

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

List types of extinguishers

All power leads clear of pipelines?

All power leads clear of access way?

Is extra ventilation required?

Type & Location

Is a water hose available & tested on site?

Communication

Has continuous communication been tested and established prior to entry?

Radio

Lifeline

Visual

Speaking

Other

Communication

Personal Protective 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

Atmospheric Testing

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

Reading

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

Entry and Exit Log

Name of entry personnel

Date & Time In
Date & Time Out

Job Completion

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

All equipment has been removed from site?

All isolations have been restored?

Sign off Authorising CSE Name & Signature

Confined Space Entry Permit - Record Checklist

This Confined Space Entry Permit template is to keep an audit log of pre-entry permits for each site

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Identification

Date and Time of entry

Entry/Access Permit Number

Confined Space Location

Description of Works

Manhole No:

Site Photo

Personnel

Entry Personnel
Entry Personnel
Name

Expiry Date of Confined Space Entry (CSE) Ticket

Surface Personnel
Surface Personnel
Name

Expiry Date of Confined Space Entry (CSE) Ticket

Isolation

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

Required Isolations to be checked by

Hot work

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

Hot work permit number

Will the Hot Works release toxic vapours?

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?

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

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

List types of extinguishers

All power leads clear of pipelines?

All power leads clear of access way?

Is extra ventilation required?

Type & Location

Is a water hose available & tested on site?

Communication

Has continuous communication been tested and established prior to entry?

Radio

Lifeline

Visual

Speaking

Other

Communication

Personal Protective 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

Atmospheric Testing

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

Reading

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

Entry and Exit Log

Name of entry personnel

Date & Time In
Date & Time Out

Job Completion

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

All equipment has been removed from site?

All isolations have been restored?

Sign off Authorising CSE Name & Signature