Information

  • Audit Title

  • Job Number

  • Job Name

1.1 Scope of Work

  • Effective date and time

  • Expires (date and time)

  • Permit issued to

  • Description of work

  • Location
  • Specific Location

  • Is continuous monitoring required?

  • Instrument
  • Serial Number

  • Most Recent Calibration

  • Field (fresh air) Calibration

  • Sensor reading for failure check

2.1 Hazards (check all that apply)

  • Flammable Atmosphere

  • Corrosive

  • Reactive

  • Toxic

  • Temperature (>100 degrees F or < 50 degrees F)

  • Engulfment

  • Other Hazards

  • Describe other hazard(s)

3.1 Preparation

  • Equipment /piping depressurized and vented

  • Equipment / piping blinded, blanked or disaligned

  • Power (forced air) ventilation

  • Electric, hydraulic, pneumatic and mechanical energy sources shut-off and locked out (zero energy state)

  • Vessel /space steamed, cleaned or washed

4.1 Entry Type

  • Horizontal

  • Vertical

5.1 Atmospheric Testing

  • Air Sample(s)

  • Air sample
  • Time

  • Oxygen Level (Action Levels: 19.5-23%)

  • %LEL (if > 10% evaluate for toxicity)

  • Hydrogen Sulfide (H2S) (PPM)

  • Carbon Monoxide (CO2)

  • Temperature

  • Atmospheric Check after isolation or forced air ventilation

  • Check after Isolation or ventilation
  • Select date

  • Oxygen Level (Action Levels: 19.5-23%)

  • %LEL (if > 10% evaluate for toxicity)

  • Hydrogen Sulfide (H2S) (PPM)

  • Carbon Monoxide (CO2)

  • Temperature

6.1 Protective Equipment

6.2 Protective Equipment (Operational)

  • Warning signs, barricades

  • Barricade tape, cones

  • Ventilation fan or blower

  • Fire equipment in place

  • GFCI'S in place

  • Lighting (hazardous location rated)

  • Grounding and/or bonding

  • Ladder

  • Other

  • Describe

6.3 Personal Protective Equipment

  • Airline respirator

  • SCBA

  • Other respirator

  • Gloves

  • Rain gear

  • Boots

  • Hearing protection

  • Safety glasses

  • Fall protection/arresting equipment

  • Chemical splash goggles

  • Other

  • Describe

7.1 Rescue Procedures and Equipment

  • Rescue plan complete

  • Emergency Number

7.2 Rescue Equipment On Site

  • Location of phone or radio

  • Full body harness / lifeline

  • Rescue winch

  • Tripod

  • Other

7.3 CSE Communication

  • Cell phone

  • Radio

  • Rope signals (OATH)

  • Sound

  • Verbal

  • Visual hand signals

  • Other

  • Emergency assembly area

  • Potential emergency situations

  • Designated Rescue Team

  • Actions to be taken

8.1 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. See entrant employee roster section of the permit for additional signatures. I have been formally trained in CSE.

  • Confined Space Entrants

  • Confined Space Entrant
  • Name and Signature (ENTRANT MUST SIGN)

9.1 Confined Space Attendant(s)

  • I have checked all rescue and communication equipment and reviewed all emergency actions to be taken with authorized entrants. I have been formally trained in CSE.

  • Confined Space Attendant
  • Name and Signature (ATTENDANT MUST SIGN)

10.1 Confined Space Entry Supervisor

  • I have complete pr properly evaluated all portions of this permit and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the permit and are adequately trained to perform this task. I have been formally trained in CSE.

  • Confined Space Entry Supervisor
  • Name and Signature (SUPERVISOR MUST SIGN)

  • Date and time

11.1 Authorized Entrant Roster

  • Date

We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment, procedures and communication methods.

  • Entrant Name and Intials

  • Entrant Name
  • Add signature

  • Date and time IN

  • Date and time OUT

12.1 Periodic Atmospheric Tests REQUIRED

    Atmospheric Test
  • Time

  • Oxygen % (O2)

  • % LEL

  • H2S

  • CO

  • Initials

13.1 Permit Cancellation

  • Job completed, high LEL, etc. Provide a brief description

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.