Confined space permit

• Brief description of work activity

• Prepared by

• Date conducted

  Date
• Location (include a brief description of work area)
  Address

• Confined Space Category

  Low Risk

  Medium Risk

  High Risk

• Has the POWRA been completed and signed by all involved?

  Yes

  No

  N/A

• STOP - complete the POWRA before works commence.

• Are all those involved hold the required level of competency ( training, knowledge & experience)

  Yes

  No

  N/A

• STOP - Contact your manager

• Have potential inflows been stopped / diverted and confirmed locked out?

  Yes

  No

  N/A

• STOP - Contact your manager

• Has the safe method of work been communicated to all involved?

  Yes

  No

  N/A

• STOP - Ensure all involved are briefed on the safe method of work before commencing.

• Have all persons involved received a company induction?

  Yes

  No

  N/A

• STOP - Contact your manager

• Have suitable exclusions been put in place (i.e., barriers, signage etc.)

  Yes

  No

  N/A

• STOP - DO NOT continue until the required barriers and signage are in place.

• Has the correct PPE been identified, issued and worn?

  Yes

  No

  N/A

• STOP - DO NOT continue until the required PPE is provided and being worn.

• Have all known risks been identified and either eliminated or reduced to an acceptable level?

  Yes

  No

  N/A

• STOP - Contact your manager

• Where required, have all COSHH Assessments been completed and Briefed?

  Yes

  No

  N/A

• STOP - Contact your manager

• Has all required Confined Space rescue apparatus been provided and in place?

  Yes

  No

  N/A

• STOP - Contact your manager

• Has all Confined Space rescue apparatus received a thorough examination within the last 6-months?

  Yes

  No

  N/A

• STOP - Contact your manager

• Has forced air ventilation been provided if applicable?

  Yes

  No

  N/A

• STOP - Contact your manager

• Has the atmosphere within the confined space been tested with a calibrated GDU and confirmed as safe for entry?

  Yes

  No

  N/A

• STOP - DO NOT entre the confined space is confirmed as safe to entre.

• Have all persons involved been made aware of the risk from Leptospirosis (Weil’s disease) cards issued?

  Yes

  No

  N/A

• STOP - Ensure all involved are made aware of the risk before commencing works.

Part 1 – Details of person entering confined space

• Name of person entering the confined space

• Confined space entry time

  Date

• confined space exit time

  Date

Part 2 – Receipt by supervisor

• A recorded briefing has been delivered to the workforce on this safe system of work

  Yes

  No

  N/A

• As the supervisor, I am familiar with the scope of work and safe systems to be implemented

  Yes

  No

  N/A

• Name

• Position

• Signature

  Sign

• Date

  Date

Part 3 – Completion by supervisor

• The activities authorised by this permit have finished and the confined space fully vacated

  Yes

  No

  N/A

• Name

• Position

• Signature

  Sign

• Date

  Date