Information

  • Job Title/Scope - Give a brief discription of the work to be undertaken.

  • Document No.

  • Conducted on

  • Prepared by

  • Risk assessment completed and job specific.

  • A full detailed risk assessment must be completed before any work commences.

  • Location

  • Sub Location

Confined Space Details

  • Project / Site Name

  • A PERMIT REQUIRED CONFINED SPACE - means an enclosed or partially enclosed space that is not designed for continuous occupancy. A confined space requires a permit if the space may contain a hazardous atmosphere; contain material that has the potential to engulf an entrant; has walls that converge inward or floors that slope downward and taper into a smaller area which could trap or asphyxiate an entrant; or contains any other recognized health and safety hazard, such as unguarded machinery, exposed live wires, or exposure to heat or cold stress.

  • Has a detailed risk assessment been completed and determined a permit is required for entering the space outlined in the job scope? (Permit required confined space)

  • Has a permit to work been completed linked to this checklist?

  • Permit to work must be completed before any work commences.

  • Permit issued to

  • Permit to work number

  • Identify potential hazards of this confined space? (select all that apply)

  • Describe other hazard(s)

Preparation

  • Space ventilated to full extent possible?

  • All people involved have completed confined space training?

  • Vehicles and plants removed from confined space to reduce fume hazard? If not, have precautions been put in place?

  • Correct confined space signage in place?

  • Space lighting in place and appropriate?

  • Access (both entry and exit) points have been identified and are clear of hazards for use?

  • Communications plan defined and understood by all involved?

  • Select methods of communication to be adopted (select all that apply)

Air Monitoring

  • Does the air of this confined space require monitoring?

  • Is the air of the confined space being continuously monitored? (as required)

  • Log air sample results

  • Air Sample
  • Time of sample

  • Sample result

  • Is this sample within acceptable parameters? Should confined space work proceed?

  • Has air monitoring equipment been calibrated?

Safety Equipment & PPE

  • Select equipment to be used in this confined space entry

  • Describe other equipment

  • Select PPE to be used in this confined space entry

  • Describe other PPE

Rescue & Emergency Plan

  • Emergency evacuation and rescue plan is complete, in place and understood by all involved?

  • Emergency Number

  • Location of phone or radio

  • Emergency actions to be taken

  • Potential emergency situations

Team Sign Off

  • Have all relevant personnel participated in pre-entry briefing?

  • Confined Space Entrants: We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. I have been formally trained in confined space entry.

  • Confined Space Entrant
  • Name and Signature (entrant to sign)

  • Confined Space Entry Supervisor: I have properly evaluated this confined space and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the entry and are adequately trained to perform this task. I have been formally trained in confined space entry and rescue.

  • Confined Space Entry Supervisor
  • Name and Signature (supervisor to sign)

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.