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Confined Space Permit To Work Template

Audit

General Details

Purpose of Entry

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)

Confined Space Permit to Work Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 81

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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