INTEGRATED MANAGEMENT SYSTEM
HEALTH, SAFETY & ENVIRONMENT
Project Name: Permit Number:
Contractor Name: Date & Time Start:
Date & Time End:
1. WORK DESCRIPTION (To Be Completed by Permit Requestor & Authorized Work Supervisor)
☐ Electrical ☐ HVAC ☐ Fire Fighting ☐ Chilled Water
Discipline:
☐ Mechanical ☐ Other:
Location of Task:
Description of Task: Note that Permit Invalid Without Task Details
2. HAZARD IDENTIFICATION (To Be Completed by Authorized Work Supervisor)
☐ Pressurized ☐ Compressed gas
PRESSURE ☐ Pressurized hose
equipment cylinders
☐ Hot / cryogenic ☐ Hot / cryogenic
TEMPERATURE ☐ Hot environment ☐ Steam
fluids surfaces
☐ Combustible
CHEMICAL ☐ Spill / Splash ☐ Flammable ☐ Toxic ☐ Fumes
material release
MOTION / ☐ Moving tools /
☐ Power tools ☐ Striking objects ☐ Friction ☐ Lifting activities
MECHANICAL machine parts
☐ Imbalanced
GRAVITY ☐ Falling objects ☐ Slips / Trips / Falls ☐ Excavation ☐ Work at height
objects
☐ Electrical shock/ ☐ Energized tools /
ELECTRICAL ☐ Electrical defects ☐ Striking objects ☐ Other:
electrocution eqpt.
☐ Loss of
☐ Thermal radiation ☐ Over / Under water ☐ Oxygen deficiency ☐ Biological
OTHER communication
☐ Noise ☐ Bad weather ☐ Pyrophoric ☐ Ionizing radiation
☐ Dust:
3. SAFETY REQUIREMENTS (To Be Completed by Authorized Work Supervisor)
Gas Test Required at Entrance and all Exhaust Locations Entrant Communication device: _______________________
Communication Between Work Crew and Standby Person Lifeline and Harness Required
Emergency Response Notified of Work Location and Duration Rescue Tripod, winches, or gantries required,
Stand-by Person Clearly Identified (Vest) and Trained on Duties SCBA Required at Location
Safe Access and Egress – Safe Ladder Access – 1m Extension Airline Equipment Required
Continuous / Periodic Gas Monitoring Required? Dust Respirator Required
Gas Monitoring Required. CO, O2, H2S & LEL Levels Measured Chemical Respirator Required
and Recorded Prior to Personnel Entering Confined Space Chemical Suit Required
LEV, Ventilation Fan/Blowers Required Disposable Coveralls Required
Ventilation Measured at Outlet (minimum flow rate 1.5 m/s) Chemical Gloves Required
Personal Atmospheric Monitoring Equipment Required Rubber Boots Required
SDS Protective Measures Reviewed for Implementation Hearing Protection Required
Remove Ignition Sources (e.g., Matches & Lighters) Face Shield Required
Confined Space Work Requires Continuous Supplied Air Low Voltage Lighting Required
Fire Extinguisher(s) Required Low Voltage Equipment Required
Flammable Material to be Used in Confined Space. If yes, specify Barricades Required
Allowable Material and Required Safety Measures Safe Condition of all Equipment has been assessed prior to use
Continuous Every Hour Every 2 Hours Every 4 Hours
Note: If Continuous Gas Testing is Not Employed, Gas Tests Must be Conducted After Breaks, Not Exceeding
1 Hour
4. JOB SPECIFIC PPE (To Be Completed by Authorized Work Supervisor)
HEAD, FACE &
Welding Helmet Face shield Welding shield Safety goggles Earmuff
HEARING
Version No. Date Form Reference Form Title Page No.
00 06-June-23 Confined Space Entry Permit Page 1 of 2
INTEGRATED MANAGEMENT SYSTEM
HEALTH, SAFETY & ENVIRONMENT
BODY / Welders Apron/ Fire retardant Fire retardant
Aluminium suit Disposable
COVERALL jacket coverall Hi-Vis
Arm leather
HAND Leather gloves Welding gloves other:
guard
Respirator
Air line SCBA set Respirator
RESPIRATORY Dust mask (Organic vapor,
(supplied) (standby) (Dust, chemical)
acid gas)
General Safety
FOOT Gumboot Welding spat Other:
boots
Portable gas
ADDITIONAL Full Body Lifeline &
Fire blanket tester (continuous Other:
PPE Harness Retractable
gas monitoring)
5. ASSOCIATED PERMITS & DOCUMENT VERIFICATION (To Be Completed by Permit Requestor)
Assess Whether Work Can be Impacted by Other Activities
Permit to Work (LOTO): Certificates:
JSA/MS, Risk Assessment (Mandatory): Others:
Pre-Start Briefing: Hot Work Permit:
Confined Space Rescue Plan: Verify Confined Space Warning Signs Posted at all
Other Permit: Entrances to Confined Space:
6. PERMIT VALIDATION
I Fully understand the requirements specified in this Permit, and I accept it is my responsibility to verify the
requirements specified have been implemented before work is started.
Name: Badge Number:
Task
Signature: Date:
Supervisor
Mobile #
Designated Name: Badge Number:
Entry Signature: Date:
Attendant Mobile #
Designated Name: Badge Number:
Permit Signature: Date:
Authority Mobile #
Name: Badge Number:
Area HSE
Signature: Date:
Officer
Mobile #
Work to Stop If: Conditions Change, stop by another party due to nearby hazards, conflicting
SIMOPS, etc.
7. PERMIT CLOSE OUT CANCELLATION
Confined Space activities have been completed, the men and equipment have been withdrawn from the
Confined Space and the area made safe and entry point sealed.
Task Supervisor: ________________________________________ Date: / /20 Time: hrs
Designated Permit Authority: _______________________________ Date: / /20 Time: hrs
Site Emergency Number: Emergency Channel, if any:
Version No. Date Form Reference Form Title Page No.
00 06-June-23 Confined Space Entry Permit Page 2 of 2
