Title Page

  • Location of Space

  • Point of Access

  • Reason for Entry

  • Duration of Entry

  • Conducted on

  • Entrant(s)

  • Other Entrant(s)

  • Attendant(s)

  • Other Attendant(s)

  • Supervisor

  • Other Supervisor

Hazards Identified

  • Identify Potential Hazards within Confined Space

  • Oxygen Hazard Present

  • Gas Hazard Present

  • Space Hazard Present

  • Temperature Hazard Identified

  • IDHL Hazard Present

  • Describe hazardous condition that poses threat to life.

  • Describe hazard that causes irreversible adverse health effects.

  • Describe hazard that interferes with unaided escape from permit space.

  • Describe type of high concentrations.

  • Other Hazard Identified

Minimal Required PPE

  • Identify Minimal Required PPE for Confined Space Entry

  • Identify Other required PPE for confined space entry

Confined Space Entry Requirements

  • Identify Confined Space Entry Requirements

  • Rescue Equipment Required

  • Describe Other Rescue Equipment Required

  • Type of Communication Required

  • Describe Other Communication Required

  • Fall Protection System Required

Emergency Response Team Notification

  • For each entry into permit required confined spaces, contact external rescue team PRIOR to entry.

  • Rescue Team

  • Rescue Team Phone #

  • Provide location, phone # of person on site, entry start time, and estimated duration. Notify again once entry is completed.

  • Called before entry

  • Signature

  • Called after entry

  • Signature

Ventilation

  • Employees shall not enter a confined space if a hazardous atmosphere exists. If at any time, the LEL exceeds the Permissible Levels,
    the employee shall immediately evacuate the confined space. Forced air ventilation is used to maintain oxygen at a safe level and prevent a hazardous concentration of flammable gasses and vapors. The air supply for forced air should be from a clean source and should not increase hazards. (i.e. vehicle exhaust)

  • Air monitor equipment tested and calibrated before use?

  • Signature

  • Meter Model & Serial #

Atmospheric Readings Before Entry

  • Ensure that all areas of the space are tested, including entrance and all applicable work spaces.

  • Date/Time

  • Location within the confined space

  • Oxygen (O2) 19.5% - 23.5%

  • Explosive LEL% < 10%

  • Hydrogen Sulfide (H2S) < 10 ppm

  • Carbon Monoxide (CO) < 35 ppm

  • Are all readings acceptable making the space safe to enter?

  • Signature

Atmospheric Readings During Entry

  • Atmospheric conditions should be continuously monitored while entrant(s) are within the confined space. Conditions should be documented every 15 minutes until the entrant(s) have exited the confined space.

  • Atmospheric Readings During Entry (Every 15 Minutes - Max 1 Hour Intervals)

  • Record of Air Monitoring Results
  • Date/Time

  • Location within the confined space

  • Oxygen (O2) 19.5% - 23.5%

  • Explosive LEL% < 10%

  • Hydrogen Sulfide (H2S) < 10 ppm

  • Carbon Monoxide (CO) < 35 ppm

  • Are all readings acceptable making the space safe to continue working?

  • Signature

Closing Permit

  • I (authorized employee) verify the above Permit is accurately completed. Written instructions and safety procedures have been received and understood by team members.

  • Entry Permit Completed By (Name & Title)

  • Entry Supervisor Signature

  • Attendant Signature

  • Entrant Signature

  • Permit Expires

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.