Confined Space Entry Permit
(Complete Prior to Entry)
Confined Space Number / Location Description / Date of EntryPurpose of Entry / Time of Entry
Plant/Job Location / Supervisor / Permit Duration (12 hours max)
Person Entering Confined Space
Last Name / First Name / Time/In / Time/Out / Time/In / Time/Out / Time/In / Time/OutCommunication Procedures (radio, speaking, mobile phone, etc.):
Pre-Entry Checklist
Yes / No / N/A / Lockout/Tagout / Yes / No / N/A / Air Testing Conducted and Recorded Yes / No / N/A / Ventilation Established / Yes / No / N/A / Gas Meter Worn
Yes / No / N/A / Area Secure - Posted, Attendant / Yes / No / N/A / Continuos Air Monitoring
Yes / No / N/A / Appropriate PPE / Yes / No / N/A / Hot Work Permit
Yes / No / N/A / Emergency Procedures Established / Yes / No / N/A / Authorized Attendant
Yes / No / N/A / Full Body Harness With D-Ring / Yes / No / N/A / Authorized Entrant
Yes / No / N/A / Rescue Equipment - Tripod / Yes / No / N/A / Entry Logged
Types of Hazards
Oxygen-Deficient Atmosphere (displaced O2) / Engulfment (sand, aggregate, cement, etc) / Energized Electrical Equipment (shock) Moving Parts (conveyor, fan, etc) / Configuration (inward sloping walls) / Respiratory Hazard (high dust levels)
Oxygen-Enriched Atmosphere (O2 leak, etc) / Toxic Atmosphere (CO, H2S) / Entrapment (in equipment)
Welding/Cutting (slag, fume, sparks, etc) / Flammable Atmosphere (LP, gas fume, etc) / Hazardous Chemical (caustic, acid, etc)
Atmospheric Testing (Record Every 2 Hours)
Testing Criteria / Permissible Entry Level / Time / Time / Time / Time / Time / Time
Percent of Oxygen / 19.5%-23.5%
Percent LEL / <10%
Percent CO / <35 ppm
Percent H2S / <10 ppm
Atmospheric Testing Equipment/Personnel
Atmospheric Tester(s) Name / Signature / Instrument Model/Type / Calibration Date
(Shows on screen) / Serial Number
Authorized Supervisor
Supervisor's Name / Signature / Date / Time
Record Keeping Checklist
Entry Permit Complete / Calibration Log / Post Entry Permit/With Attendant / Permit In Log Book