CX Paving Solutions - Permit to Work in Confined Spaces

• Client / Site

• Permit to Work in Confined Space Location

• Conducted on

  Date

• Conducted by

Supervisor Information

• Permit to Work in Confined Space Location

• Detail the Purpose of the work

• All Hazards have been assessed (e.g. Absence of Oxygen)?

  Yes

  No

  N/A

• A Method Statement for the work has been fully prepared?

  Yes

  No

  N/A

• Escape Equipment and emergency procedures are in place?

  Yes

  No

  N/A

• Employees involved have been trained and are competent?

  Yes

  No

  N/A

• The guidance provided in Activity Assessment 22 has been followed?

  Yes

  No

  N/A

• The employees concerned have been given suitable and sufficient information?

  Yes

  No

  N/A

• Documented evidence is attached to substantiate the above?

  Yes

  No

  N/A

• The Supervisor of the Works and their contact details are:

• Enter any further information / notes / instructions

• The permit is valid for (Enter No. Days)

Supervisor Signoff

• Authorisation to proceed

  Sign

Operatives Signoff

• The operatives involved in the work have understood the method of work, received specific instructions, are aware of the hazards (including location and depth) and how they have been marked

  Sign

Completion signoff

• Works completed and left in a safe condition

  Sign