Confined Space Permit - Adaptable training Pertnerships

• Audit Title

• Job Number

• Job Name

CONFINED SPACE ENTRY PERMIT

All Questions must be answered yes in order to proceed with this CSE Permit.

• All personal are trained and competent to enter and work in CSE ?.

  No

  Yes

• A current Risk assessment has been completed for this CSE ?.

  YES

• All other options to avoid CSE have been considered prior to CSE ?.

  YES

Does this permit combine with any other permits ?

• Isolation Permit

  No

  Yes

• Hot Works

  No

  Yes

• Working At Heights

  No

  Yes

• Other

  No

  Yes

• Excavation

  No

  Yes

1.1 Scope

• Effective date and time

  Date

• Expires (date and time)

  Date

• Department / Contract Company

• Description of work

• Location
  Address

• Specific Location

• Is continuous monitoring required?

  No

  Yes
Instrument

• Serial Number

• Most Recent Calibration

  Date

• Field (fresh air) Calibration

  Pass

  Fail

• Sensor reading for failure check

2.1 Hazards (check all that apply)

• Flammable Atmosphere

• Corrosive

• Reactive

• Toxic

• Temperature (>100 degrees F or < 50 degrees F)

• Engulfment

• Other Hazards

• Describe other hazard(s)

3.1 Atmosphere

• Will Hot Works be conducted in the CSE ?

  No

  Yes

  N/A

• Will Chemicals be used in the CSE ?

  No

  Yes

  N/A

• Will forced air extraction / ventilation be required ?

  No

  Yes

  N/A

• Are there any combustion engines running nearby - CO fumes ?

  No

  Yes

  N/A

• Is Humidity control required ?

  No

  Yes

  N/A

• Is SCBA (Breathing aparatice) or any air supply system required (Airline) ?

  No

  Yes

  N/A

3.2 Engulfment

• Will entry or Exit be restricted or difficult ?

  No

  Yes

• Does the pit or trench wall need to be secured (Shored up) ?

  No

  Yes

  N/A

• Is there any medium above or below the space ?

  No

  Yes

  N/A

• Are there any un-isolated energy sources that could affect the CSE personal ?

  No

  Yes

  N/A

• Has a suitable means of access and egress be arranged ?

  No

  Yes

  N/A

3.3 General

• Is the standby person trained and competent ?

  No

  Yes

• Are signs and barricades required for this CSE ?

  No

  Yes

  N/A

• Are safety Harness required for this CSE ?

  No

  Yes

• Is communication equipment required ?

  No

  Yes

• Is intrinsically safe equipment required ?

  No

  Yes

  N/A

• Are alternative access (second entry point) methods controls required ?

  No

  Yes

  N/A

• What are the current weather conditions for this entry ?

  Fine

  Overcast

  Raining

  Storms

  Cyclones

Appropriate Controls have been implemented for any YES response to questions above ?

• YES

4.1 Entry Type

• Horizontal

• Vertical

5.1 Atmospheric Testing

• Air Sample(s)

Air sample

• Time

  Date

• Oxygen Level (Action Levels: 19.5-23%)

• %LEL (if > 10% evaluate for toxicity)

• Hydrogen Sulfide (H2S) (PPM)

• Carbon Monoxide (CO2)

• Temperature

• Atmospheric Check after isolation or forced air ventilation

Check after Isolation or ventilation

• Select date

  Date

• Oxygen Level (Action Levels: 19.5-23%)

• %LEL (if > 10% evaluate for toxicity)

• Hydrogen Sulfide (H2S) (PPM)

• Carbon Monoxide (CO2)

• Temperature

6.Personal Protective Equipment

• Airline respirator

• SCBA

• Other respirator

• Gloves

• Rain gear

• Boots

• Hearing protection

• Safety glasses

• Fall protection/arresting equipment

• Chemical splash goggles

• Other

• Describe

7.1 Rescue Procedures and Equipment

• Rescue plan complete and attached

• Emergency Number

• Location of phone or radio

7.2 Rescue Equipment On Site

• Full body harness / lifeline

• Rescue winch

• Tripod

• Other

7.3 CSE Communication

• Cell phone

• Radio

• Rope signals (Tag Line)

• Sound

• Verbal

• Visual hand signals

• Other

• Emergency assembly area

• Potential emergency situations

• Designated Rescue Team

• Actions to be taken

8.1 Confined Space Permit Issuer

• As the issuing person I authorise the entry to this Confined Space subject to the conditions and precautions of the risk assessment and as indicated on this Permit.

• Add signature

  Sign

• Select date

  Date

9.1 Confined Space Standby

• I have advised Emergency Services of this CSE ?

  No

  Yes

• I have checked all rescue and communication equipment and reviewed all emergency actions to be taken with authorized entrants. I have been formally trained in CSE. I have checked all entrants are trained and competent in CSE. I have briefed all entrants on the rescue plan, communications plan, actions on alarm, hydration plan.

• Confined Space Attendant / Standby / Sentry

Confined Space Attendant

• Name and Signature (ATTENDANT MUST SIGN)

  Sign

• date and tme

  Date

10.1 Confined Space Entry Permit Holder (Supervisiour)

• I have properly evaluated all portions of this permit and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the permit and are adequately trained to perform this task. I have been formally trained in CSE.

• Confined Space Entry Permit Holder (Supervisor)

Confined Space Entry Permit holder (Supervisiour)

• Name and Signature (SUPERVISOR MUST SIGN)

  Sign

• Date and time

  Date

11.1 Authorized Entrant SIGN IN

• We (I) have read, understood and agree with the risk assessment. We (I) have all signed onto the Risk Assessment. We (I) understand and will conform to the conditions of entry indicated on this permit and will adhere to all conditions and precautions on the attached risk assessment.

Confined Space Entrant

• Add signature

  Sign

• Select date

  Date

11.2 Authorised Entrant SIGN OUT

CSE Entrants to SIGN OUT

• Add signature

  Sign

• Select date

  Date

12.1 Re - Atmosphere Test :

• Date & Time :

  Date

• Oxygen Level (Action Levels: 19.5-23%)

• %LEL (if > 10% evaluate for toxicity)

• Hydrogen Sulfide (H2S) (PPM)

• Carbon Monoxide (CO2)

13.1 Permit Close Out (Cancilation) To be completed by the CSE Supervisiour.

• All personal have exited the CSE ?

  YES

• All equipment has been removed and checked ?

  YES

• The CSE has been secured ?

  Yes

  No

  N/A

• Emergency Services have been advised of the CSE completion and all staff have excited ?

  YES

• Name and Signature (Supervisiour)

  Sign

• Select date

  Date

• Job completed any additional comments ? Any hazards identified etc