Site Safety & Administration
Confined Space Entry Permit
Entry permit for work in a confined space such as a tank, pit, silo, sewer or vessel, as required by the model WHS Regulations. Records isolations, atmospheric testing, standby person, rescue arrangements and entry/exit log.
39 checklist items
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Checklist Items
| Item | Pass / Yes | Fail / No |
|---|---|---|
| PERMIT DETAILS | ||
| Permit Number | ___________________________ | |
| Site / Project | ___________________________ | |
| Confined Space Identification and Location | ___________________________ | |
| Date | ___________________________ | |
| Valid From / Until (Time) | ___________________________ | |
| Purpose of Entry / Work to be Done | ___________________________ | |
| Confined space risk assessment reference | ___________________________ | |
| PERSONNEL | ||
| Authorised Entrant(s) Name(s) | ___________________________ | |
| Standby Person Name | ___________________________ | |
| Rescue Team / Rescue Personnel | ___________________________ | |
| All personnel trained in confined space entry for this work | Yes ☐ | No ☐ |
| ISOLATION & PREPARATION | ||
| Pipelines, valves and services isolated, locked and tagged | Pass ☐ | Fail ☐ |
| Mechanical and electrical plant isolated and verified dead | Pass ☐ | Fail ☐ |
| Space cleaned, purged and drained as required | Pass ☐ | Fail ☐ |
| Signage and barricades in place at all entry points | Pass ☐ | Fail ☐ |
| Forced ventilation set up (if required) | Pass ☐ | Fail ☐ |
| ATMOSPHERIC TESTING | ||
| Gas detector ID and bump test / calibration date | ___________________________ | |
| Oxygen (%) (safe range 19.5 to 23.5) | ___________________________ | |
| Flammable gas (% LEL) (must be below 5%) | ___________________________ | |
| Hydrogen sulphide (ppm) | ___________________________ | |
| Carbon monoxide (ppm) | ___________________________ | |
| Other contaminants tested and results | ___________________________ | |
| Continuous monitoring in place during entry | Yes ☐ | No ☐ |
| Tested By / Time of Test | ___________________________ | |
| EQUIPMENT & RESCUE | ||
| Communication method between entrant and standby agreed and tested | Pass ☐ | Fail ☐ |
| Harness, retrieval line and tripod / davit set up (where practicable) | Pass ☐ | Fail ☐ |
| Respiratory protection suitable for the hazard (if required) | Pass ☐ | Fail ☐ |
| Intrinsically safe lighting and tools (if flammable risk) | Pass ☐ | Fail ☐ |
| Rescue plan prepared and rescue equipment at entry point | Pass ☐ | Fail ☐ |
| First aid equipment available | Pass ☐ | Fail ☐ |
| AUTHORISATION | ||
| Permit Issuer Name | ___________________________ | |
| Permit Issuer Signature | ___________________________ | |
| Standby Person Signature | ___________________________ | |
| Entrant(s) Signature | ___________________________ | |
| ENTRY / EXIT LOG | ||
| Entrant name, time in, time out (record each entry) | ___________________________ | |
| CLOSE-OUT | ||
| All persons, tools and materials out of the space | Yes ☐ | No ☐ |
| Space secured and isolations removed / handed back | Yes ☐ | No ☐ |
| Time Permit Closed | ___________________________ | |
| Permit Issuer Close-Out Signature | ___________________________ | |