Demo One DOA-20 Confined Space Permit to Work

• Project Number

• Site Address
  Address

• This Permit is Valid From (Date & Time)

  Date

• This Permit is Valid Until (Date & Time)

  Date

• THIS PERMIT COVERS ENTRY TO

• Site Specific Location of Work for Permit Use

• PLEASE NOTE: This Confined Space Permit to Work which must be signed, briefed and authorised prior to the work, MUST also be used in conjunction with the Confined Space: Emergency Plan (next section).
  
  ZERO HARM
  

  

• THIS PERMIT IS AUTOMATICALLY SUSPENDED UPON THE SOUNDING OF ANY EMERGENCY ALARM OR IN THE EVENT OF ANY ACCIDENT, DANGEROUS INCIDENT OR OCCURRENCE.

CONDITION OF RESTRICTED AREA

• Atmosphere Tested

  Yes

  No

  N/A

• Adequate Supply of Fresh Air

  Yes

  No

  N/A

• Any Machinery/Plant Isolation Required

  No

  Yes

  N/A

SPECIAL PRECAUTIONS

• Protective clothing to be worn

  No

  Yes

  N/A

• Rescue procedures

  No

  Yes

  N/A

• Safety belt/lifeline to be worn

  No

  Yes

  N/A

• Forced ventilation to be provided

  No

  Yes

  N/A

• Breathing apparatus to be worn

  No

  Yes

  N/A

• Watchers to be posted

  No

  Yes

  N/A

• Any other precautions

  No

  Yes

  N/A

• Please list other precautions below

AUTHORISATION

• Prepared and Authorised by Site Supervisor

  Sign

RECEIPT

• Name and Signature of Operative 1 Performing the Task

  Sign

• Name and Signature of Operative 2 Performing the Task

  Sign

• Name and Signature of Operative 3 Performing the Task

  Sign

• Name and Signature of Operative 4 Performing the Task

  Sign

• Name and Signature of Operative 5 Performing the Task

  Sign

• Name and Signature of Operative 6 Performing the Task

  Sign

• Name and Signature of Operative 7 Performing the Task

  Sign

• Name and Signature of Operative 8 Performing the Task

  Sign

• Name and Signature of Operative 9 Performing the Task

  Sign

• Name and Signature of Operative 10 Performing the Task

  Sign

CANCELLATION: On cancellation no further works can take place until a new permit is issued

• Cancelled by Site Supervisor

  Sign

EMERGENCY ACTION PLAN CONTACTS

• Enter Name of Attendant

• Attendant's Deputy

• Enter Name of Site Supervisor

• Site Supervisor's Deputy

• Enter Name of Authorised Person

• Authorised Person's Deputy

• Enter Name of Rescue Team Contact

• Rescue Team Contact's Deputy

EMERGENCY CATEGORY 1: Due to the nature of confined space where all life is at risk i.e. explosion, fire, oxygen deficiency etc.

• 1. Attendant shall prevent access by others

• 2. Attendant shall notify other emergency action personnel

• 3. Attendant shall ensure emergency services are called on 999

• 4. Attendant shall ensure rescue team is actioned

EMERGENCY CATEGORY 2: Due to non-confined space related accident i.e. individual has received broken bones etc.

• 1. Attendant shall prevent access by others

• 2. Attendant shall notify other first aider who is

• Other first aider information

• 3. Attendant shall ensure emergency services are called on 999

• 4. Attendant shall notify other emergency action personnel

• Number and Type

EMERGENCY EQUIPMENT CHECK: PREVENTATIVE

• Ventilation

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Communications

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Escape Breathing Apparatus

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Full Breathing Apparatus

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Air Monitor

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Other

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

EMERGENCY EQUIPMENT CHECK: RESCUE

• Harness

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Lifeline

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Winch

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Stretcher

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• First Aid Equipment

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Resuscitator

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Intrinsically Safe Lamps

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Fire Equipment

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose

• Other

Equipment

• Number in use

• Type

• Location

• Checked as fit for purpose