Form
Confined space entry permit
Task details
Building/location:
Organisation:
Confined space No.:
Date:
Description of space:
Reason for entry:
Task Analysis (to be completed by the person conducting the work or supervising the work)
Y
N
Has the risk assessment for entry into this confined space type been conducted and/or reviewed?
☐
☐
2 Have all measures been taken to eliminate or minimise the requirement for entry?
☐
☐
3 Is the space connected to systems or sources that require isolation?
☐
☐
☐
☐
☐
☐
5 Is there potential for the work to create a hazardous atmosphere? (If ‘Yes’ continuous monitoring of the
atmosphere will be required
☐
☐
6 Is hot work to be conducted within a confined space? (If ‘Yes’ Hot Work permit must be attached)
☐
☐
7 Do access points restrict entry / exit or the ability to extract a person (See ‘Access’ and ‘Rescue’)
☐
☐
8 Are there substances in the space (other than those in Q4 & 5 that may be harmful to health?
☐
☐
If ‘Yes’, if available PPE suitable to provide the required protection? (See ‘PPE’)
☐
☐
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1
(see ‘Isolations’ below)
4 Is there potential for the atmosphere in the space to be hazardous?
If ‘Yes’, has the atmosphere been tested?
(see ‘Atmosphere’ below)
9 Are there free flowing materials in the space that may result in engulfment?
Isolations
Isolations required:
☐ Electrical
☐ Mechanical
☐ Pipelines
☐ Fire System
☐ Other
Detail:
Atmosphere (test results prior to entry)
LEL %
<5 CO ppm
30 (TWA)
O2 %
19.5 - 23.5 H2S ppm
Other gases:
10 (TWA) CO2 %
<1
Other containments:
Is purging required? ☐ Yes ☐ No If yes, specify gas used:
Is continuous monitoring required? ☐ Yes ☐ No If yes, specify frequency:
Respiratory requirements:
☐ Nil/natural ventilation
☐ Mechanical ventilation
☐ Self-contained air
☐ Supplied air line
☐ Extraction
☐ Respirator
Equipment requirements
Access
☐ Signage
☐ Barriers
☐ Lighting
☐ Ladder/platform
☐ Tripod & winch
☐ Edge protection
PPE
☐ Thermal protection
☐ Eye protection ☐ Head protection
☐ Ear protection
☐ Full body harness
☐ Two way radio ☐ Chemical suit
☐ Other:
1 of 2
Last modified: 6 February 2016
Reference Number: DHSE-FRM-0021
Document Name: Document1
☐ Gloves
☐ Boots
Confined space entry permit
Rescue and emergency
☐ Air breathing rescue kit ☐ Tripod & winch
☐ Spreader beam
☐ Retrieval hooks
☐ Straps
☐ Personal gas detectors ☐ Bolt cutters
☐ Hacksaw
☐ Crowbar/prybar
☐ Ropes & rigging
☐ Search camera
☐ Other (detail):
Rescue plan (provide detail on potential events that may require rescue and the rescue shall be achieved)
Persons involved
Supervisor of the work
Name:
Appointment:
Phone No.:
Stand-by person(s)
Person(s) entering the space
Declaration by supervisor of the work: The work described on this permit is considered safe to commence
using precautions listed above and all persons performing this work are appropriately trained and qualified.
Name:
Signature:
Date:
Approval by permit issuing officer: The work described on this permit is considered safe to commence
using precautions listed above and is approved for the period specified.
Period of the permit:
Name:
Signature:
Date:
Entry Log: Record all movement in and out of the confined space (initialled by person upon exit)
Name
In
Out
Initial
Name
In
Out
Initial
Atmospheric monitoring record
Time
LEL
(%)
CO (ppm)
O2
(%)
H2S (ppm)
CO2
(%)
Supervisor declaration on completion of work: The work described on this permit is complete and all
persons and equipment involved have vacated the space. All isolations have been removed and the space has
been secured.
Name:
Signature:
Date:
Return to Permit Issuing Officer on completion
2 of 2
Last modified: 6 February 2016
Reference Number: DHSE-FRM-0021
Document Name: Document1