Working in confined spaces poses numerous hazards to workers and entrants such as asphyxiation or loss of oxygen which leads to suffocation. Commencement of work must not begin until the appropriate level of authority has endorsed the Permit to Work. This template can be used record the mode of communication and rescue procedures to determine the team’s preparedness during emergencies. Next conduct a pre-work check to assess if safety equipment and measures are in place to prevent accidents and injuries. Capture photo evidence of equipment defects or non compliances to confined space protocols. List all people involved in the work being performed.
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Title Page
Permit Number
Contractor
Site Location
Conducted on
Prepared by
General Details
Purpose of Entry
Communication Procedures
Other communication procedures
Rescue Procedures
Click + to add rescue procedures
Procedure
Enter details here
Pre-Work
Indicate whether the following items are completed and reviewed before entry
Lockout/Deenergize/Tagout
Line(s) Broken-Capped-Blank
Purge-Flush and Vent
Ventilation
Secure Area (Post and Flag)
Breathing Apparatus
Resuscitator - Inhalator
Standby Safety Personnel
Full Body Harness Body with D ring
Emergency Escape Retrieval Equipment
Lifelines
Fire Extinguishers
Lighting (Explosive Proof)
PPE
Respirators (Air Purifying)
Hot Work Permit (Buring and Welding)
Completion
Click + to add names of people involved
Person
Full Name, Signature and Position of Person Involved (e.g. Sheen Meyer - Entrant)
SafetyCulture Staff
Confined Space Permit To Work Template
Working in confined spaces poses numerous hazards to workers and entrants such as asphyxiation or loss of oxygen which leads to suffocation. Commencement of work must not begin until the appropriate level of authority has endorsed the Permit to Work. This template can be used record the mode of communication and rescue procedures to determine the team’s preparedness during emergencies. Next conduct a pre-work check to assess if safety equipment and measures are in place to prevent accidents and injuries. Capture photo evidence of equipment defects or non compliances to confined space protocols. List all people involved in the work being performed.
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions.
The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice.
You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction.
You should independently determine whether the template is suitable for your circumstances.
