Confined Space

• Location / Site

• Prepared by

• Conducted on

  Date

Confined Space

• Photos

  Media

• Where is the confined space located:

• Works being conducted in confined space:

• Permit. / Clearance is current

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Communications in place, suitable and understood by employees

  Yes

  No

  N/A

• Safe access provided – external / Internal

  Yes

  No

  N/A

• Pre-entry assessment completed

  Yes

  No

  N/A

• Rescue procedure in place and available in SWMS

  Yes

  No

  N/A

• Stand by person in place, trained, understands responsibilities

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Low voltage lighting installed & functional where required

  Yes

  No

  N/A

• PPE requirements identified in SWMS and complied with

  Yes

  No

  N/A

• Rescue equipment in place / available

  Yes

  No

  N/A

• Other findings:

• Name:

• Select date

  Date

• Signature:

  Sign