Confined space rescue Entry permit - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Assessment

• Date and time?

  Date

• Entry supervisor name

• Type of access.

• Contents of confined space?

• Is there an existing permit?

  Yes

  No

• Name of reporting party or person?

• Number of victims?

• Time last seen?

  Date

• Is MSDS Available?

  Select Yes No

  • Yes
  • No

• Rescue or Recovery

  Rescue

  Recovery

Hazards InSpace

• Types of Hazards

  Select Mechanical Electrical Pneumatic Hydraulic Engulfment Temperature Substance Pipes and Ducts Other

  • Mechanical
  • Electrical
  • Pneumatic
  • Hydraulic
  • Engulfment
  • Temperature
  • Substance
  • Pipes and Ducts
  • Other

• O2

• LEL

• CO

• H2S

• Other

• Sample Time

  Date

• Tester Name

Hazard Control

• Ventilation

  Positive Pressure

  Negative Pressure

  Combination

• Mechanical

  Select Block Linkage Disconnect Other

  • Block Linkage
  • Disconnect
  • Other

• Electrical

  Select lock Out Tag Out Disconnect

  • lock Out
  • Tag Out
  • Disconnect

• Hydraulic

  Select Lock Out Tag Out Bleed Lines Disconnect Lines

  • Lock Out
  • Tag Out
  • Bleed Lines
  • Disconnect Lines

• Piping

  Select Blind Disconnect

  • Blind
  • Disconnect

• Pneumatic

  Select Lock Out Tag Out Bleed Lines Disconnect Lines

  • Lock Out
  • Tag Out
  • Bleed Lines
  • Disconnect Lines

Operation Checks

• Confirm Lock-Out / Tag-Out

  Yes

  No

  NA

• Ventilation

  Yes

  No

  NA

• Atmospheric Monitoring

  Yes

  No

  NA

• Eliminate Ignition Sources

  Yes

  No

  NA

• Provide Lighting

  Yes

  No

  NA

• Protective Clothing

  Yes

  No

• Respiratory Protection

  Select SCBA SAR NA

  • SCBA
  • SAR
  • NA

• Communication

  Select Visual Hardwired Radio Voice

  • Visual
  • Hardwired
  • Radio
  • Voice

• Radio Channel

  Select Red White Blue Gold Gray

  • Red
  • White
  • Blue
  • Gold
  • Gray

• Victim Packaging

  Select Stokes Half Back SKED Harness Reeves Sleeve Other

  • Stokes
  • Half Back
  • SKED
  • Harness
  • Reeves Sleeve
  • Other

• Is RIT teem in place?

  Yes

  No

• Has pre entry and safety briefing been done?

  Yes

  No

Perfsonnel

• Incident Commander

• Safety Officer

• Entrant 1

• Entrant 2

• Entrant 3

• Entrant 4

• Attendant 1

• Attendant 2

• RITA 1

• RIT 2

• Air Supply

• Other

• Other