Confined Space Entry

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Confined Space Entry Procedure and Permit

• Select date

  Date

• Location

• Type of Space

  Manhole

  Vault

  Other

• If Other Specify:

• Reason For Entry:

• Approved Barricades in Place

  Yes

  No

  N/A

• Rescue plan in place?

  Yes

  No

  N/A

Hazard Monitoring-Atmosphere

Oxygen

• Initial Oxygen% by volume

• Final Oxygen % by volume

• Within limits? 19.5%< Oxygen % <23.5%

  Yes

  No

  N/A

Carbon Monoxide

• Initial Carbon Monoxide (ppm)

• Final Carbon Monoxide (ppm)

• Carbon Monoxide less than 35ppm?

  Yes

  No

  N/A

Hydrogen Sulfide (H2S)

• Initial Hydrogen Sulfide PPM

• Final Hydrogen Sulfide PPM

• Hydrogen Sulfide below 1 PPM?

  Yes

  No

  N/A

Lower Flammability Limit (LFL)

• Initial Percent LFL

• Final Percent LFL

• LFL below 10%

  Yes

  No

  N/A

Hazard Monitoring-Other

• What other hazards are present?

  Select Noise Heat Electrical Steam Gas Powered Equipment Water Using Chemical Product in Space Insect/Animal Other None of the above

  • Noise
  • Heat
  • Electrical
  • Steam
  • Gas Powered Equipment
  • Water
  • Using Chemical Product in Space
  • Insect/Animal
  • Other
  • None of the above

• If any of the above are selected, describe actions being taken to eliminate or control the hazard.

• Forced air ventilation used?

  Yes

  No

  N/A

• If yes above, is air from clean source?

  Yes

  No

  N/A

• Full body harness worn by entrant?

  Yes

  No

  N/A

• Full body harness inspected before use?

  Yes

  No

  N/A

• Rescue tripod in use?

  Yes

  No

  N/A

Entrance/Exit Time

• Time Entered

  Date

• Time Exit

  Date

Personnel

• Authorized Attendant

• Attendant Trained?

  Yes

  No

  N/A

• Authorized Entrant

• Entrant trained?

  Yes

  No

  N/A

• Authorized Entrant

• Entrant trained?

  Yes

  No

  N/A

• Authorized Entrant

• Entrant trained?

  Yes

  No

  N/A

• Authorized Entrant

• Entrant trained?

  Yes

  No

  N/A

• Authorized Entrant

• Entrant trained?

  Yes

  No

  N/A

Supervisor

• Name of Entry Supervisor

• Title of Entry Supervisor

• Entry Supervisor Signature

  Sign