Information
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Document No.
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Client Name
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Client Contact
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Conducted on
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Prepared by
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Location
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Personnel
SECTION 1 - Risk Assessment
SECTION 1 - Risk Assessment
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Document the hazards and analyse the risks associated with the entry and work activities to be undertaken with respect to the confined space
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Reason For Entry
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Description of Work Activity
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Nature of Work to be Undertaken
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Confined Space to be Entered
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Description of Confined Space
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Confined Space Catagory
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MINIMUM STANDARD ENTRY CONTROLS
- A pre-entry atmospheric test -
MINIMUM STANDARD ENTRY CONTROLS
- Pre-entry venting to ensure a safe atmosphere
- A pre-entry atmospheric test
- A stand-by person to be in constant communication with entry personnel -
MINIMUM STANDARD ENTRY CONTROLS
- Pre-entry and continuous venting to ensure a safe atmosphere
- A pre-entry atmospheric test and continuous atmospheric monitoring
- A stand-by person to be in constant communication with entry personnel
- Provision of retrieval and rescue equipment at the immediate confined space location -
Please consult your Test & Poly Supervisor
Risk Assessment Guide
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Step 1 - Consider Concequences
What are the consequences of this hazard occurring? Consider what is the most probable consequence (below) with respect to this work hazard -
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Step 2 - Consider Likelihood
What is the likelihood (below) of the hazard consequence in Step 1 occurring? -
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Step 3 - Calculate Risk
1. Take Step 1 Rating and select the correct column
2. Take Step 2 Rating and select the correct row
3. Use the risk score where the two ratings cross on the below matrix
E = Extreme
H = High
M = Moderate
L = Low -
Hazard Identification
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Slips, Trips and Falls
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Controls to Manage the Hazard
- Tools Lanyard
- Compliant Ladder
- PPE -
Other Controls Required?
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Clearly list any other Controls required
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Responsible Party to Implement Controls
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Who is responsible to implement the nominated controls
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Risk Rating with all nominated Controls in place
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Traffic and/or pedestrians
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Controls to Manage the Hazard
- Barricades & Signage
- Traffic Control & Devices -
Other Controls Required?
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Clearly list any other Controls required
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Responsible Party to Implement Controls
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Who is responsible to implement the nominated controls
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Risk Rating with all nominated Controls in place
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Chemical / Fume Inhalation
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Controls to Manage the Hazard
- Induction, Venting and/or Extraction
- Gas Detecting & Monitoring -
Other Controls Required?
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Clearly list any other Controls required
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Responsible Party to Implement Controls
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Who is responsible to implement the nominated controls
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Risk Rating with all nominated Controls in place
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Drowning
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Controls to Manage the Hazard
- Pump out all Water
- Check Plug Integrity Prior to Entering -
Other Controls Required?
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Clearly list any other Controls required
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Responsible Party to Implement Controls
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Who is responsible to implement the nominated controls
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Risk Rating with all nominated Controls in place
Risk Assessment Personnel
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Name, Employer and Signature
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Select date
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Name, Employer and Signature
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Select date
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Name, Employer and Signature
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Select date
SECTION 2 - Entry Permit
SECTION 2 - Entry Permit
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Isolation Controls
This Confined Space needs to be isolated from -
Water / Gas / Steam / Chemicals
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Mechanical / Electrical Drives
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Hydraulic / Electric / Gas / Power
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Sludge / Deposits / Waste
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Auto Fire Extinguishing Systems
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Locks &/or Tags will be Affixed to Isolation Points
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Other
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Purging, Ventilation & Atmospheric Monitoring Controls
This Confined Space requires the following -
Depressurising
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Opening / Venting
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Continuous Purging / Extraction
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Atmospheric Testing Required for
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Oxygen (O2)
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Carbon Monoxide (CO)
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Hydrogen Sulphide (H2S)
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Carbon Dioxide (CO2)
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LEL
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Ammonia (NH3)
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Volatile Organic Compounds (VOC)
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Other
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Type of Testing / Monitoring Required
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Initial Only - Prior to entry and each subsequent day
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Continuous for Atmospheric Contaminants
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Continuous for Flammable Contaminants
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Communication & Stand By Controls
Minimum Requirements will include -
One Stand By Person
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Two or More Stand By Persons
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Rescue Team
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Communication Via Voice and Direct Sight
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Communication Via Radio
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Communication Via Hand Signals and Other Means
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Rescue / Retrieval Considerations
Minimum Provisions are to include -
Stand By Person to individually handle
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Safety Harness / Rescue Kit in vicinity with competent user(s)
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Specific access to platforms/scaffolding erected
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Specific Fire fighting provisions
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First aid kit in vicinity
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Other
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Personal Protective Equipment (PPE) Requirements
Minimum items required -
Supplied breathing apparatus
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Air purifying respirator
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Particulate mask
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Safety harness and lanyard / lifeline
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Head protection
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Face shield / goggles / safety glasses
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Ear muffs / plugs
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Gloves
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Warning notices / barricading
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Specific lighting provisions
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Specific hot work controls
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Other
Permit Request
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This acknowledgement signifies a formal request to commence confined space entry / works. As the person requesting this permit, I hereby certify that; 1. I am competent to coordinate this confined space entry / work in accordance with the previous Risk Assessment & Entry Permit details; 2. I shall undertake to implement all planned and necessary controls to ensure safe entry / work; 3. I shall monitor confined space hazards and control methods throughout the entry / work;
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Time & Date Signed
Permit Authorisation
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This authorisation signifies that the planning component of the Risk Assessment & Entry Permit has been completed and that the confined space entry / work is authorised to commence in accordance with the Permit Request.
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Time & Date Signed
SECTION 3 - Implementation
SECTION 3 - Implementation
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
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Atmospheric Test Results
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Test Time & Date
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NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
NOT SAFE TO ENTER
Re-Test and confirm safe limits with supervisor -
Other
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Gas Detector Number
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Entry Permitted?
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Personnel taking results
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Another test
Entry Authorisation
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The procedures, control measures and precautions appropriate for the safe entry / work in this confined space have been implemented and the persons required to work in the confined space have been David of and understand the requirements of the Risk Assessment & Entry Permit
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Time & Date Signed
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CONSTRAINTS This Entry Authorisation is valid until the following occurs or the time and date shown
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Select date
Personnel Entry
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I the undersigned, hereby acknowledge that I fully understand the procedure, control measures and precautions to be observed with the entry / work and exit involved with this confined space. I will comply with these requirements at all times and report any unforeseen hazard that presents a risk to safety
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Add signature
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Select date
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Add signature
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Select date
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Add signature
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Select date
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Add signature
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Select date
Withdrawal of Entry Authorisation
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All persons and equipment has been accounted for and the equipment and confined space has been restored correctly and safely
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Select date
