Confined Space Permit To Work Template

• Permit Number

• Contractor

• Site Location
  Address

• Conducted on

  Date

• Prepared by

General Details

• Purpose of Entry

• Communication Procedures

  Visual

  Life line

  Voice Contact

  Radio Signal

  Other

• 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

  Yes

  No

  N/A

• Line(s) Broken-Capped-Blank

  Yes

  No

  N/A

• Purge-Flush and Vent

  Yes

  No

  N/A

• Ventilation

  Yes

  No

  N/A

• Secure Area (Post and Flag)

  Yes

  No

  N/A

• Breathing Apparatus

  Yes

  No

  N/A

• Resuscitator - Inhalator

  Yes

  No

  N/A

• Standby Safety Personnel

  Yes

  No

  N/A

• Full Body Harness Body with D ring

  Yes

  No

  N/A

• Emergency Escape Retrieval Equipment

  Yes

  No

  N/A

• Lifelines

  Yes

  No

  N/A

• Fire Extinguishers

  Yes

  No

  N/A

• Lighting (Explosive Proof)

  Yes

  No

  N/A

• PPE

  Yes

  No

  N/A

• Respirators (Air Purifying)

  Yes

  No

  N/A

• Hot Work Permit (Buring and Welding)

  Yes

  No

  N/A

Completion

• Click + to add names of people involved

Person

• Full Name, Signature and Position of Person Involved (e.g. Sheen Meyer - Entrant)

  Sign