Title Page
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Site conducted
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Plant/Area:
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Employee/Contractor Name:
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Conducted on
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Prepared By:
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Line Manager:
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Location
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Permit Number
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Permit Issuer
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Permit Acceptor
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Higher Authority (if applicable)
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Has confined space entry controls been identified and signed by higher authority (if applicable) (verify on the field)
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Has the initial gas testing been done before the permit is issued? (if applicable)
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Are gas tests conducted as per frequency and noted on the permit? (if applicable) (verify on the plant)
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Is the vessel properly decontaminated? (Check adequacy of decontamination method)
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Have all electrical equipment been isolated and locked out? (Check the lock numbers and verify on plant)
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Has the lock-out register been completed/Updated? (verify permit number corresponds to the lock out register and that the lock numbers on the field corresponds to those on the permit and register)
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Is the vessel positively isolated and blank/spade list attached to the permit?
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Is the vessel guarded against unauthorised entry when there is no standby? (check if there is a ‘UNAUTHORISED ENTRY” cross bars)
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Is the vessel adequately ventilated and free of toxic or explosive gases? (Force ventilation, extraction fans etc.)
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Is there a rescue plan in place for the work being conducted in a confined space?
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Are safety measures put in place where safe atmosphere cannot be guaranteed? Check if respirators, breathing apparatus, airline masks used to mitigate chemical exposure? (Verify on permit)
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Are Emergency equipment available at the work site as prescribe in the permit
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Comments: Where deviations have been noted, indicate the corrective action taken. Also report the matter to the supervisor. Look for other hazards that might have been missed in the risk assessment.
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Auditor's Signature
