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Confined Space Entry Permit

The document is a Confined Space Entry Permit that outlines essential information for safe entry into a confined space, including site details, equipment, and personnel involved. It includes a pre-entry safety checklist to ensure all safety measures are in place and a log for tracking entrants. The permit requires signatures from authorized personnel to confirm compliance with safety protocols.

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wellvision.wo
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67 views4 pages

Confined Space Entry Permit

The document is a Confined Space Entry Permit that outlines essential information for safe entry into a confined space, including site details, equipment, and personnel involved. It includes a pre-entry safety checklist to ensure all safety measures are in place and a log for tracking entrants. The permit requires signatures from authorized personnel to confirm compliance with safety protocols.

Uploaded by

wellvision.wo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CONFINED SPACE ENTRY PERMIT

Basic Information

Site Name
Site Address
Confined Space Location
Date
Permit-to-Work Number
Confined Space Number
Description of Work

Equipment To Be Used Inside


Confined Space:

Emergency Contact Number

Confined Space Controller:

Name Position CS License # Expiry Date Signature

Atmospheric Monitoring
Date Time Oxygen (%) CO (ppm) Combustible H2S (ppm) Tester’s
Gas (%) Signature

Oxygen Level Min. 19.5%, Max. 23.5%, Combustible Gas - Max. 5% L.E.L.

Confined Space Entrants

Name Position CS License # Expiry Date

Emergency Response Team (must be briefed on the nature of the CSE and the location)

CS Expiry Briefed on Nature of


Name Position
License # Date CSE

Pre-Entry Safety Checklist

Safety Measures Yes No


Confined space risk assessment completed (Identify all hazards and implement
mitigation measures)
Work team briefed on hazards and emergency response (Confirm all team members
understand procedures)
Atmosphere tested and safe entry confirmed (Monitor gas levels and confirm safe
oxygen levels)
Ventilation system in place (Ensure airflow prevents hazardous gas accumulation)
Permit signed by authorized personnel (Obtain necessary approvals for confined space
entry)
Emergency rescue plan reviewed and standby personnel in place (Ensure rescue team is
on standby)
Harness and fall arrest system inspected (Check for proper fit and good condition)
Lockout/Tagout (LOTO) applied where required (Prevent unintended activation of
hazardous systems)
Communication system established and tested (Confirm reliable contact between inside
and outside personnel)
Personal protective equipment (PPE) checked and worn as required (Ensure all workers
wear necessary protective gear)
Lighting and visibility confirmed adequate (Provide sufficient lighting for safe work
conditions)
Tools and equipment inspected and ready for use (Ensure all tools are in good working
condition and safe to use)

Additional Requirements/Special Conditions

Authorisation

Issued By (Name) Signature Position Date Time

Accepted By (Name) Signature Position Date Time

CONFINED SPACE ENTRY LOG

Name Time In Signature Time Out Signature

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