Confined Space Rescue Plan

• Conducted on

  Date

• Prepared by

• Client

• Facility Name

• Facility Address
  Address

• Confined Space Name

• Purpose for Entry

• Entry Type

  Horizontal

  Vertical

  Other

• Other Entry Type

• Nearest Exit Door or Muster Spot

Additional Permits

• Permit

  Select Confined Space Entry Permit Hot Work Permit Safe Work Permit Work from Height LOTO Other

  • Confined Space Entry Permit
  • Hot Work Permit
  • Safe Work Permit
  • Work from Height
  • LOTO
  • Other

• Other

Emergency Communication

• Communication Type

  Select Phone Radio On location

  • Phone
  • Radio
  • On location

• Phone Number

• Radio Channel

Emergency Alarms

• Alarm Type

  Select Fire / Smoke / Heat Chemical Release Evacuation Tornado Other

  • Fire / Smoke / Heat
  • Chemical Release
  • Evacuation
  • Tornado
  • Other

• Chemical Name

• Other Alarm

Hazards

• Hazards Present

  Select Oxygen Deficient Oxygen Enriched Flammables Combustible Dust Toxic Gases/Vapors Engulfment Electrical Shock Skin Hazards Heat Stress Entrapment Corrosive Materials Physical Hazards in Space Mechanical Hazards Other

  • Oxygen Deficient
  • Oxygen Enriched
  • Flammables
  • Combustible Dust
  • Toxic Gases/Vapors
  • Engulfment
  • Electrical Shock
  • Skin Hazards
  • Heat Stress
  • Entrapment
  • Corrosive Materials
  • Physical Hazards in Space
  • Mechanical Hazards
  • Other

• Other Hazard Present

• Hazard Controls

  Select Barriers Safety Glasses/Goggles Face Shields Appropriate Gloves Safety Shoes/Boots Rubber Boots Hearing Protection Hard Hat SCBA or SAR Fire Extinguisher Respirator Continuous Air Monitoring Forced Ventilation Ground Fault Circuit Interrupters Artificial Lighting – Low Voltage Mechanical Lift Welding/Cutting Tools Outside Unless in Use Adequate Work Platform Fall Protection or Prevention system Safety Coveralls Other

  • Barriers
  • Safety Glasses/Goggles
  • Face Shields
  • Appropriate Gloves
  • Safety Shoes/Boots
  • Rubber Boots
  • Hearing Protection
  • Hard Hat
  • SCBA or SAR
  • Fire Extinguisher
  • Respirator
  • Continuous Air Monitoring
  • Forced Ventilation
  • Ground Fault Circuit Interrupters
  • Artificial Lighting – Low Voltage
  • Mechanical Lift
  • Welding/Cutting Tools Outside Unless in Use
  • Adequate Work Platform
  • Fall Protection or Prevention system
  • Safety Coveralls
  • Other

• Respirator Type

  Yes

  No

  N/A

• Other Hazard Control

Rescue Equipment Requirements

• Potential Rescue Equipment

  Select Harness Life Line Rescue Rope Rope Rigging Tripod Davit System Anchor Point(s) Winch Retractable Life Line D-Ring Strap Crane Basket Stretcher Roll-up Stretcher Polycarbonate Slide Sheet AED First Aid Kit SCBA or SAR Rescue Air Bottle Radio Communication Line of Sight Head Lamp Other

  • Harness
  • Life Line
  • Rescue Rope
  • Rope Rigging
  • Tripod
  • Davit System
  • Anchor Point(s)
  • Winch
  • Retractable Life Line
  • D-Ring Strap
  • Crane
  • Basket Stretcher
  • Roll-up Stretcher
  • Polycarbonate Slide Sheet
  • AED
  • First Aid Kit
  • SCBA or SAR
  • Rescue Air Bottle
  • Radio Communication
  • Line of Sight
  • Head Lamp
  • Other
Additional Rescue Equipment Requirements

• Additional Information

Rescue Plan Notes

• Plan of Rescue

• Include in plan of rescue, means of notification, arrival procedures, actions of primary and secondary rescuer and facility responsibilities.

Space Information

• Pictures

  Media

• Drawing

  Drawing

• Plan Includes

  Select Entry and exit points Location of rescue equipment Evacuation point(s) Emergency assembly area Location of Identified hazards Participants in rescue team Role of team members Role of workers involved Anchorage points Other

  • Entry and exit points
  • Location of rescue equipment
  • Evacuation point(s)
  • Emergency assembly area
  • Location of Identified hazards
  • Participants in rescue team
  • Role of team members
  • Role of workers involved
  • Anchorage points
  • Other

• Also Included

• Participants in the rescue team have been briefed on the rescue plan prior to the work commencing?

  Yes

  No

  N/A

• Rescue equipment checked and available?

  Yes

  No

  N/A