Information

  • Project Name

  • Prepared by

  • Title

  • Project Manager

  • Conducted on

  • Add location

A. Confined Space Evaluation

  • 1. Personnel informed of location and hazards of existing confined spaces (danger signs, verbal)

  • 2. Determination made that work can not be completed without entering the confined space

  • 3. Information obtained regarding the space (blue prints, potential hazards, energy sources)

  • 4. Spaces classified as permit-required, alternative procedure, or nonpermit confined spaces

B. Training

  • 5. Entrants, Attendants, and Entry Supervisor have completed confined-space entry training

  • 6. Employees performing lockout/tagout procedures have completed LOTO training

  • 7. Employees required to wear respirators have completed respiratory protection training

C Confined Space Entry

  • 8. Completed permit or certificate posted at space entrance

  • 9. Preentry briefing conducted

  • 10. Entrants/Attendants verify that entry supervisor has authorized entry

  • 11. Entrants/Attendants verify that all requirements of the permit or certificate have been satisfied

  • 12. Atmospheric monitoring is conducted at frequency provided on the permit or certificate

  • 13. Entry not permitted if an atmospheric hazard is detected above acceptable safe levels

  • 14. Entrants evacuate space upon orders of the attendant or entry supervisor, when an alarm is sounded, or when a prohibited condition or dangerous situation is recognized<br>

  • 15. Entrants/Attendant informs entry supervisor of hazards confronted or created in the space or any problems encountered during entry. <br>

  • 16. Entry supervisor informs the owner of such issues in item 15 above

D. Entry Under a Confined Space Entry PERMIT (CSEP)

  • 17. CSEP completed by entry supervisor

  • 18. All expected hazards listed

  • 19. Entry supervisor and Attendant assigned

  • 20. Communication methods established between entrants and the attendant <br>

  • 21. Cleaning requirements identified

  • 22. Isolation requirements identified

  • 23. Ventilation requirements identified

  • 24. Protective equipment requirements

  • 25. Rescue equipment requirements identified

  • 26. Other requirements identified

  • 27. Rescue and emergency procedures identified

  • 28. Atmospheric monitoring requirements identified

  • 29. HS&E manager approve use by signing (CH2M HILL CSEP only)

  • 30. Entry supervisor authorized entry by signing

  • 31. Authorized entrants have completed CSE training and attended preentry briefing

  • 32. Only authorized entrants permitted to enter the space

  • 33. Entry supervisor sign the CSEP indicating its cancellation

  • 34. Problems encountered during the entry listed<br>

E. Entry Under An Alternative Procedure Certificate (APC)

  • 35. APC completed by entry supervisor

  • 36. All expected atmospheric hazards listed

  • 37. Entry supervisor and Attendant assigned

  • 38. Entry supervisor verifies that nonatmospheric hazards do not exist

  • 39. Communication methods established between entrants and the attendant

  • 40. Covers removed safely

  • 41. Openings guarded from both fall hazards and from objects entering the space

  • 42. Continuous forced-air ventilation positioned to ventilate the immediate areas where employees are working and continue until they have left the space<br>

  • 43. Ventilation from a clean source of air

  • 44. Atmospheric monitoring requirements identified .

  • 45. Entry supervisor authorize entry by signing

  • 46. Authorized entrants have completed CSE training and attended preentry briefing

  • 47. Only authorized entrants permitted to enter the space

  • 48. Entry supervisor sign the APC indicating its cancellation

  • 49. Problems encountered during the entry listed<br>

F. Entry Under a Non-Permit Certificate (NPC)

  • 50. NPC completed by entry supervisor

  • 51. Entry supervisor assigned

  • 52. Attendant or buddy assigned

  • 53. Buddy remains in the space with the entrant

  • 54. Entry supervisor verifies nonatmospheric hazards do not exist

  • 55. Communication methods established between entrants and attendant or buddy

  • 56. Entrants informed to exit the space immediately if hazards are observed

  • 57. Atmospheric monitoring requirements identified

  • 58. Entry supervisor authorizes entry by signing.

  • 59. Authorized entrants have completed CSE training and attended preentry briefing

  • 60. Only authorized entrants permitted to enter the space

  • 61. Entry supervisor shall sign the NPC indicating its cancellation

  • 62. Problems encountered during the entry shall be listed

G. Rescue

  • 63. Entrants wearing body harness with attached retrieval line (lifeline)<br>

  • 64. Other end of lifeline attached to retrieval device (when required) or fixed point outside space <br>

  • 65. Mechanical retrieval device positioned at access point for vertical-type spaces > 5 feet deep

  • 66. Rescue team established

  • 67. Team members have completed confined-space entry training

  • 68. Team members informed of the hazards that they may confront during rescue operations

  • 69. PPE & rescue equipment necessary to conduct safe entry-rescue provided & readily available

  • 70. Team members trained on rescue duties and proper use of PPE and rescue equipment

  • 71. All team members trained in first aid & CPR, at least one member holding a current certification

  • 72. Team has made simulated rescue from a space of similar configuration within last 12 months

  • 73. Communication established & tested between the team & entrants, and emergency provider

  • 74. Local emergency medical provider notified in advance of entries into PRCS

H. Atmospheric Monitoring

  • 75. Qualified individual conducts atmospheric monitoring

  • 76. Monitoring results documented on permit or certificate

  • 77. Entrants do not enter until all monitoring requirements are completed

  • 78. Monitoring equipment calibrated prior to use

  • 79. Monitoring conducted for oxygen, flammability, and toxic air contaminants

  • 80. Monitoring conducted bottom to top at five foot intervals

I. Pre-Entry Briefing

  • 81. Entry supervisor conducts the briefing and discusses the follow items:

  • 82. Explanation of the work to be performed and limitations

  • 83. Explanation of actual and potential hazards, including the possible behavioral effects and signs, symptoms, and consequences of exposure<br>

  • 84. Review of the control measure and atmospheric monitoring requirements, as specified on permit or certificate<br>

  • 85. Review of entrant and attendant responsibilities

Corrective Action Taken

  • Corrective actions & dates corrected

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.