Confined Spaces Permit

Applicability: This permit establishes that all hazards have been identified and controlled and it lists
the confined space entry supervisor and authorised entrants and attendants. For more information,
see Confined Spaces Standard HSW-SSTD-HPC-036

Instructions: This form must be signed by the authorising person (Section 6) before entry and it must
be kept at the works location. Once the work is completed, the authorising person must close the
permit by signing Section 7.

NB – Working in a confined space is strictly prohibited unless all other practicable measures
not to enter have been considered

1. Permit Conditions Permit No. …………………...

Reason for entry: Entry date:
Permit expiry(date and time):
Entrant: Acceptable entry conditions:
Entrant:
Entrant:
Attendant:
Attendant:

Location/Site Address:

Known and potential hazards:

Additional required permits (for example hot work):

2. Requirements Checklist (tick all that apply and specify as necessary)

Personal protective equipment and personal
Equipment
monitors
Full Body Harness Tripod/hoist Gloves Leather Impervious

Lifeline Gloves Chemical Other

Warning Signs Guarding Face / Eye Protection Face Shield

Ladder Fall Protection Goggles Other :-

Ventilation Fan or blower Coveralls (Type) :-

Fire Extinguisher (Type) :- Footwear (Type) :-

Self Contained breathing apparatus (SCBA) Head Protection

Air purifying respirator (cartridge type) :- Gas Monitors

Other :- Other :-

Other :- Other :-

Other :- Other :-

Authorised By: K Lowthian Page 1 of 3 HSW-FOR-HPC-013

Author: A Kerr Date: June 2019 Version: 1.1

As part of our system review, this document is valid until October 2019
 Confined Spaces Permit
3. Pre-entry Checklist (tick all that apply and specify as necessary)
Entry to confined space is necessary Control of hazardous energy
Verify adequate confined space training Lockout / tag out Zero voltage verification

Pre-entry briefing on specific hazards and Communication Radio

control methods
Verbal Hand/Rope signals

Notify subcontractors of permit and hazard

Lighting
conditions

Non-entry rescue and procedure in place Hazardous location rated Standard

Drain space Purging
Other :- Preliminary

Other :- Continuous
Other :- Other :-

4. Personnel Entry & Exit record (to be completed before and during the work)
Entrant name: Attendant Entrant Attendant Entrant Attendant
name: name: name: name: name:

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Time out

Time in

Notes:

Authorised By: K Lowthian Page 2 of 3 HSW-FOR-HPC-013

Author: A Kerr Date: June 2019 Version: 1.1

As part of our system review, this document is valid until October 2019
 Confined Spaces Permit
5. Air Monitoring Results (to be completed as needed before and during work)
Device/s Serial number
1.
2.
Time Sampled O2 CO Other:
by
(19.5–23.5%) (<25 ppm)

6. Pre-entry Certification (must be signed by the confined space authorising person before
entry)
I hereby certify that all required hazard controls are in place, that air monitoring is being conducted as
required and results show that the atmosphere is acceptable for entry, and that all required
information is documented on this permit.
Confined space entry authorising person for this entry:
Signature: Date:

7. Permit Closure (must be signed by the confined space authorising person after work is
completed)
The work was done in accordance with this permit. A copy of this permit will be forwarded to the
confined space Operations/Project Manager.
Name:
Signature: Date:

Authorised By: K Lowthian Page 3 of 3 HSW-FOR-HPC-013

Author: A Kerr Date: June 2019 Version: 1.1

As part of our system review, this document is valid until October 2019