CONFINED SPACE DOCUMENTATION
Entry Permit, Gas testing, Hazard Management, Rescue Plan, Entry Log
CONFINED SPACE ENTRY PERMIT
Confined Space Description
.
Work to be done ;
Name of Person in Charge of Entry (Permit Issuer)
Name of Person Controlling Entry (Permit Receiver)
Company:
Date : Time:
Isolations required? Y N Isolation Register Attached Y N
OR
List Isolation Points (that protect entrants from product and moving parts):
Identify entry point location:
Additional equipment required to carry out for a safe entry (i.e. scaffold):
Identify any Hot Work:
Is Gas Testing Required during Entry Y N Gas testing Period Every _________ Minutes
Competent Person initial Gas Name: Sig.
Testing.
Make/Model Testing Next Test Date Due.
Equipment:
Date Time Oxygen LEL H2S CO Tester Name
19.5% - 23.5% Max 5% CE Max 10ppm Max 25ppm
Desired 20.9% 1% HW Desired 0ppm Desired 0ppm
Desired 0%
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Gas Testing Record
Date Time Oxygen LEL H2S CO Tester Name
19.5% - 23.5% Max 5% CE Max 10ppm Max 25ppm
1% HW
Desired 20.9% Desired 0% Desired 0ppm Desired 0ppm
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CONFINED SPACE HAZARD IDENTIFICATION and RISK ASSESSMENT
Physical and atmospheric hazards, and control measures to reduce the risk.
Risk assessment with the control measures in place.
Person responsible for instigating the control measure.
Risks Risk Control Methods Low-High Responsible
All Confined Space hazards All entrants and safety standby person 1,2,3,4,5 Permit Receiver
can be identified and trained and competent to identify new
controlled. hazards and instigate control methods.
Hold U.S. 18426
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
1,2,3,4,5
IS WORK NOTIFIABLE TO WORKSAFE NZ? YES NO
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CONFINED SPACE RESCUE PLAN
STANDBY PERSON COMMUNICATION METHODS
Stand-by to Entrants:
Stand-by to Emergency Service:
STAND BY PERSON IMMEDIATE ACTIONS IN THE EVENT OF AN EMERGENCY
Raise Alarm by;
Other Actions;
Potential Rescue Scenarios and Planned method of rescue
(Change scenarios as required; document planned rescue method)
1. Entrant collapses in confined space. (reason unknown)
2. Serious injury in the confined space. (injured unable to self-rescue)
3. On site emergency. (i.e. fire)
Rescue equipment required to be located at the entry point
The Confined Space Entry Authorisation
To be completed prior to Entry;
I confirm that as the Permit Receiver I will ensure that all personnel under my control working in or about the
confined space will work to the risk controls mentioned. If the hazards change I will evacuate the confined space
and withdraw entrants until the hazards are controlled and a new permit authorised.
Permit Receiver Name Sign.
The confined space is in a safe condition for entry, provided that all the hazards identified are fully controlled, any
changes to the work method or changing hazards the entry must be reauthorized.
This Permit is valid from: This Permit is valid to:
Date; Time; Date; Time;
Person Authorising the Entry Permit Name: Sign.
(Permit Issuer)
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CONFINED SPACE ENTRY LOG
Safety Stand-by Person Name: Sign.
Safety Stand-by Person Name: Sign.
Safety Stand-by Person Name: Sign.
The Confined Space Entry Log Must be controlled by the Safety Standby Person at all times
First Name Surname Time in Time Signed out
out
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Withdrawing or Closing the Permit
I confirm that the confined space work is completed /withdrawn (circle one).
All personnel and equipment have been withdrawn from the confined space, and it is safe to be put back into
operation.
(Permit Receiver) Name: Sign.
The confined space work is: -
complete and normal work can resume.
incomplete and further work is as detailed below: -
(delete as applicable)
This Permit is closed on:
Date: Time:
Permit Issuer Name: Sign.
When this document is completed, and the permit closed it should be handed to the Safety
Manager for audit purposes.
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