• THIS CHECKLIST IS TO BE COMPLETED PRIOR TO ALL CONFINED SPACE ENTRIES AND ONLY GOOD FOR SINGLE ENTRY. EMAIL A COPY OF THE ENTRY CHECKLIST TO THE DISTRICTS H&S COORDINATOR UPON COMPLETION. Checklist must be completed by an RPS Confined Space Competent Person.

1. IDENTIFICATION

  • Date and Time of Entry

  • Confined Space Location/Space Identifier Number

  • Description of Work Performed

  • Description of Space to be Entered

  • Site Photo

2. PERSONNEL

  • Enter the names of Entry Personnel

  • Enter the names of Outside Attendant Personnel.

  • Relevant Emergency contact numbers are accessible on site ?

3. ISOLATION LOTO (required by each person entering space)

  • Electrical Isolation Required

  • Mechanical Isolation Required

  • Gas/Oil Supply Required

  • Space has been allowed time to cool off Required

  • Required Isolation in Place - Checked by

  • Signature

4. ATMOSPHERIC TESTING (before entering)

  • Four Gas Meter Calibration Date

  • Recommended Levels

  • Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

  • Record Peak Test Readings Prior To Entry

  • Oxygen (%)

  • Explosive Gas (LEL%)

  • Hydrogen Sulphide (ppm)

  • Carbon Monoxide (ppm)

  • Other Gases Tested

  • NOTE: IF ANY OF THE ITEMS ABOVE DO NOT PASS THE PRE-ENTRY TEST THE ENTRY IS CANCELLED. DO NOT ENTER A SPACE THAT FAILS THE ATMOSPHERIC TEST AT ANY TIME!

4-1. ATMOSPHERIC TESTING (post entering)

  • Recommended Levels

  • Oxygen b/w 19.5% to 23.5% : Explosive Gas <5% LEL : Hydrogen Sulphide <10ppm : Carbon Monoxide <30ppm

  • Record Peak Test Readings after exiting space.

  • Oxygen (%)

  • Explosive Gas (LEL%)

  • Hydrogen Sulphide (ppm)

  • Carbon Monoxide (ppm)

  • Other Gases Tested

  • NOTE: IF ANY OF THE ITEMS ABOVE DO NOT PASS DURING THE ENTRY THE ENTRY IS CANCELLED. DO NOT ENTER A SPACE THAT FAILS THE ATMOSPHERIC TEST AT ANY TIME!

5. VENTILATION

  • Natural

  • Forced

6. REVIEW CONDITIONS THAT MAY CHANGE STATUS OF CSE

  • Select any of the following that will be taken into consideration before entry into the Confined Space

  • Weather

  • Traffic

  • Noise

  • Dust or Odors

7. PERSONAL PROTECTION EQUIPMENT

  • Select relevant PPE to be worn or carried by persons entering the Confined Space.

  • Hard Hat, Boots, Safety Vest

  • Gloves

  • Eye Protection

  • Hearing Protection

  • Overalls or Protective Clothing

  • 2 Way Radio

  • Fall Arrest Device

  • Harness

  • Platforms

  • Lighting

  • Ladders

  • Fire Extinguisher

9. Emergency Information

  • In the event of an emergency requiring rescue, dial 911 and send someone to escort RFD to the entry location. Never enter a confined space where an atmosphere alarm has been triggered and the entering employee has lost consciousness.

10. APPROVAL TO ENTER

  • The Confined Space described in this Entry Checklist is isafe to enter using precautions listed above and all persons are properly trained to perform this work.

  • Name and Signature

  • Select date

11. JOB COMPLETION

  • All persons have left the Confined Space. No further Entries Permitted without New Permit

  • Name and Signature

  • Select date

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