VUW Permit To Work - Confined Spaces

• Permit Type

• Site Conducted
  Address

• Conducted on

  Date

• Contractor

• Project or Program Name

• Prepared by

Pre-Work

• Indicate whether the following items are completed and reviewed before entry

• Is this confined space identified in the Confined Spaces register?

  Yes

  No

  N/A

• Do any electrical services require Lock out tag out (LOTO)?

  Yes

  No

  N/A

• Will there be any Hot Work taking place in the confined space?

  Yes

  No

  N/A

• Is an approved Hot Works permit present?

  Yes

  No

  N/A

• Are there any gas, air lines, sprinkler or other service lines that require purging and/or capping?

  Yes

  No

  N/A

• Have all vents or extraction systems been checked as functioning before works begin?

  Yes

  No

  N/A

• Is passive ventilation available if electrical ventilation requires isolation?

  Yes

  No

  N/A

• Is the work area effectively secured and cordoned off to prevent unauthorised entry?

  Yes

  No

  N/A

• Will Breathing Apparatus be required or used for the planned works?

  Yes

  No

  N/A

• Is an emergency Resuscitator - Inhalator required for the type of works or type of confined space?

  Yes

  No

  N/A

• Are Standby Safety Personnel required and on hand?

  Yes

  No

  N/A

• Will working at height equipment be required for access and during works being completed?

  Yes

  No

  N/A

• Has working at height equipment been inspected and passed?

  Yes

  No

  N/A

• Is a means of Emergency Escape Retrieval Equipment on hand and in good working order?

  Yes

  No

  N/A

• Are Lifelines required for these works and if so are they present and set up in good order?

  Yes

  No

  N/A

• Will other emergency equipment or PPE be used during these works?

  Yes

  No

  N/A

• Is additional task lighting (intrinsically safe) required?

  Yes

  No

  N/A

• Are appropriate Fire Extinguishers available and accessible in the confined space?

  Yes

  No

  N/A

• Is any other type of air monitoring or purifying required in the confined space to work safely?

  Yes

  No

  N/A

• Are gas monitors in place or portable monitors being used

  Yes

  No

  N/A

• Is a fire protection system shutdown required before works start

  Yes

  No

  N/A

• What is the chosen method of Communication during the confined space works?

  Visual

  Life line

  Voice Contact

  Radio Signal

  Other

• What are the communication procedures for this method and are they documented in the risk assessment?

Rescue Procedures

• Is the emergency rescue procedure detailed in the risk assessment and known to all workers?

  Yes

  No

  N/A

• What emergency rescue method has been selected

Permit Issuer

• Name of the Permit issuer

• Signature of Permit issuer

  Sign

Contractor Sign Off

• Name of person in charge of confined space works

• Signature of supervisor in charge

  Sign

• Click + to add names of people involved