Title Page

  • Location / Site

  • Prepared by

  • Conducted on

Confined Space

  • Photos

  • Where is the confined space located:

  • Works being conducted in confined space:

  • Permit. / Clearance is current

  • Permit / Clearance requirements complied with – access, gas monitoring, isolation, house keeping, ventilation etc.

  • Safe work procedures, Relevant SWMS in place, MSDS’s, attached to Permit / Clearance and complied with.

  • Communications in place, suitable and understood by employees

  • Safe access provided – external / Internal

  • Pre-entry assessment completed

  • Rescue procedure in place and available in SWMS

  • Stand by person in place, trained, understands responsibilities

  • Correct signage in place “Confined Space No Unauthorised Entry”.

  • Low voltage lighting installed & functional where required

  • PPE requirements identified in SWMS and complied with

  • Rescue equipment in place / available

  • Other findings:


  • Name:

  • Select date

  • Signature:

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