Rochester Public Schools - Confined Space Entry Permit updated 2019

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• 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

  Date

• Confined Space Location/Space Identifier Number

• Description of Work Performed

• Description of Space to be Entered

• Site Photo

  Media

2. PERSONNEL

• Enter the names of Entry Personnel

• Enter the names of Outside Attendant Personnel.

• Relevant Emergency contact numbers are accessible on site ?

  Yes

  No

  N/A

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

• Electrical Isolation Required

  Yes

  No

  N/A

• Mechanical Isolation Required

  Yes

  No

  N/A

• Gas/Oil Supply Required

  Yes

  No

  N/A

• Space has been allowed time to cool off Required

  Yes

  No

  N/A

• Required Isolation in Place - Checked by

• Signature

  Sign

4. ATMOSPHERIC TESTING (before entering)

• Four Gas Meter Calibration Date

  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

  Yes

  No

  N/A

• Forced

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

• Traffic

  Safe

  At Risk

  N/A

• Noise

  Safe

  At Risk

  N/A

• Dust or Odors

  Safe

  At Risk

  N/A

7. PERSONAL PROTECTION EQUIPMENT

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

• Hard Hat, Boots, Safety Vest

  Yes

  No

  N/A

• Gloves

  Yes

  No

  N/A

• Eye Protection

  Yes

  No

  N/A

• Hearing Protection

  Yes

  No

  N/A

• Overalls or Protective Clothing

  Yes

  No

  N/A

• 2 Way Radio

  Yes

  No

  N/A

• Fall Arrest Device

  Yes

  No

  N/A

• Harness

  Yes

  No

  N/A

• Platforms

  Yes

  No

  N/A

• Lighting

  Yes

  No

  N/A

• Ladders

  Yes

  No

  N/A

• Fire Extinguisher

  Yes

  No

  N/A

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

  Sign

• Select date

  Date

11. JOB COMPLETION

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

• Name and Signature

  Sign

• Select date

  Date