FSA CSE permit {Training}

• Site conducted
  Address

• Conducted on

  Date

• Prepared by

  Sign
• Location
  Address

• Work Location

• Purpose/Type of Work

• Start Time {in 24 hour time}

• Expected Duration {minuets}

• Department/Contracting Company

• Does this Permit combine with any other permits? Associated Doc. No. (JHA SWP, RA etc)

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Associated Doc. No. (JHA SWP, RA etc)

Associated permits

• Isolation {permit number in notes}

  Yes

  No

  N/A

• Hot Work {permit number in notes}

  Yes

  No

  N/A

• Working with Heights {permit number in notes}

  Yes

  No

  N/A

• Dig {permit number in notes}

  Yes

  No

  N/A

• Other (provide details in notes)

  Yes

  No

  N/A

Atmosphere considerations

• Will welding / hot works be conducted with in space

  Yes

  No

  N/A

• Will chemicals be used within the confined space

  Yes

  No

  N/A

• SDS avaliable

  Yes

  No

  N/A

• Is intrinsically safe equipment required

  Yes

  No

  N/A

• Is ventilation or extraction required

  Yes

  No

  N/A

• Type of ventilation

  Select Natural Positive pressure Negative pressure Positive and negative pressure

  • Natural
  • Positive pressure
  • Negative pressure
  • Positive and negative pressure

• - Are there any internal combustion engines nearby or fume potential?

  Yes

  No

  N/A

• Is raspatory protection required

  Yes

  No

  N/A

• RPE selection

  Select P2 maks Canister respirator Positive pressure respirator SCBA Air line SCBA N/A

  • P2 maks
  • Canister respirator
  • Positive pressure respirator
  • SCBA
  • Air line SCBA
  • N/A

Engulfment

• Are there any un-isolated energy sources that could affect people in the confined space

  Yes

  No

  N/A

• Is there any medium above or below the space that could limit access

  Yes

  No

  N/A

• Have the hole/trench walls been secured if required

  Yes

  No

  N/A

• Has suitable means of access and egress been established

  Yes

  No

  N/A

• Type on entry

• Will entry and exit be restricted or difficulted

  Yes

  No

  N/A

General

• Is the standby person trained and competent

  Yes

  No

  N/A

• Is barricading/signs required to confirm the space

  Yes

  No

  N/A

• Is additional lighting required

  Yes

  No

  N/A

• Lighting equipment

• Is safety harnesses required to be worn

  Yes

  No

  N/A

• Communication equipment required?

  Yes

  No

  N/A

• Communication equipment

• Have assessed the hazard controls in place for this job and it is consistent with the risk assessment requirement

  Yes

  No

  N/A

Atmosphiec testing

• Atmospheric testing

  Yes

  No

  N/A

• Continuous monitoring required

  Yes

  No

  N/A

• Intervals between testing {minuets}

Pre entry gas testing

• Date of test

  Date

• Name of person conducting Gast test

  Sign

• LEL <5%

• Oxygen 19.5% - 23.5%

• Hydrogen Sulphide <10ppm

• Carbon Monoxide <30ppm

• First aid kit on site or available

  Yes

  No

  N/A

• Basic emergency rescue kit available

  Yes

  No

  N/A

• Has a effective and tested means of communicating with Emergency Services been established

  Yes

  No

  N/A

• Emergency phone number internal

• Emergency phone number external

• Emergency phone radio channel

• is a rescue plan required and has been developed and attached to this permit

  Yes

  No

  N/A

As the issuing person, I authorize the entry to this Confined Space subject to the conditions and precautions of the risk assessment and as indicated on this Permit.

• Permit issuer

  Sign

• Date of permit issue

  Date

As the Entry Permit Holder I accept this Permit and agree to be bound by the conditions above, the associated procedures, and accept the responsibility as the person directly in charge of the work in the confined space/s nominated

• Permit holder

  Sign

• Date of permit issue

  Date

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign

• Work party member

  Sign