Company Name

Logo

DEPARTMENT
CONFINED SPACE PERMIT
Document Number: Revision Number: Page: Date:
00 Page 1 of 2
This permit must be signed by the authorised Competent Person in direct control of work before any work proceeds.
Only the listed work may be carried out.

Site:
Date: Person in Charge of Work:

GENERAL
Location of task: Permit Number:
Description of task:

Permit Issuer: Signature, Date and Time:

Work cannot proceed until a completed JSA and /or a risk assessment is available
RISK CONTROL MEASURES (All sections must be completed)
Requirements
Pre-entry requirements YES NO N/A YES NO N/A
Lockout - Tagout/de-energize Hot work permit
Pipes(s) broken or capped or blanked Fall arrest harness/
Purge, flush or drain Lifeline/Tripod
Ventilation: Hardhat
Secure area Gloves
Safe lighting Safety glasses
Non-sparking tools Respirator, type
Communication method: Breathing Apparatus
Contractor employees involved Other PPE:
Additional info or equipment required for safety: Emergency Rescue
Procedures in place and communicated to staff Yes / No
Space-monitoring results Test 1 Test 2 Test 3 Test 4
Monitor at least every four hours Permissible entry Time: Time: Time: Time:
levels Initial: Initial: Initial: Initial:
Percent oxygen 19.5% to 23.5%
Combustible gas Less than 10% LEL
Other toxic gas
Other toxic gas
Other gases:

Yes No
Possible atmospheric hazards YES NO N/A
Lack of oxygen
Combustible gases
Combustible vapours
Combustible dusts
Toxic gases/vapours
Possible non-atmospheric hazards
Noise
Chemical contact
Electrical hazard
Mechanical exposure
Temperature extreme
Engulfment
Entrapment
Other non-atmospheric hazardsCopy of permit must remain at the job site until work is completed Page 1 of 2
Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.
 Other Precautions Required
Warning notices/barricades
Smoking forbidden
All persons have been trained
Intrinsically safe equipment
Communication equipment

Number of Stand-by personnel required:

Name and Phone number:

Department and Phone Number:

Entry Supervisor or Qualified Person Signature:

AUTHORITY TO ENTER
The risk control measures and precautions appropriate for the safe entry and execution of the tasks in the
confined space has been implemented and the persons required to work in the confined/restricted space have been advised of
and understand the requirements of this written authority.

Name:

Signed:………………………………………..
(Authorised Competent Person in direct control) Date:………………… Time:………...

This written authority is valid until: Date: ………………… Time: …………….

PERSONS REQUIRED TO ENTER CONFINED SPACE

We have been advised of and understand the risk control measures and precautions to be observed for entry, exit and work in
the confined space.
ENTRY EXIT
Name/Signature Date Time Name/Signature Date Time

CANCELLATION OF PERMIT YES NO

All persons and equipment, plant and materials accounted for
Equipment checked and restored correctly
Work has been completed
Access to the space has been secured

Name: Signed:

Date: Time:
Copy of permit must remain at the job site until work is completed Page 2 of 2
Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.
 Remarks or comments:

The completed form must be maintained on file

Copy of permit must remain at the job site until work is completed Page 3 of 2
Disclaimer: Hard copies of this document are considered uncontrolled. Please refer to the safety office latest version.