Confined Space Entry Permit
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supervisor
First Name
Last Name
Confined Space Location/Name
Purpose of Entry
Permit Closure
Entry Log
Rows
Time in
Time Out
Entry 1
Entry 2
Entry 3
Entry 4
Hazards of Confined Space
Rows
Yes
No
Controlled
Oxygen deficiency
Combustible gas/vapor
Combustible dust
Carbon Monoxide
Hydrogen Sulfide
Toxic gas/vapor
Toxic fumes
Skin- chemical hazards
Electrical hazard
Mechanical hazard
Engulfment hazard
Entrapment hazard
Thermal hazard
Slip or fall hazard
Special Requirements
Rows
Yes
No
Controlled
Hot Work Permit Required
Lockout/Tagout
Lines broken, capped, or blanked
Purge-flush and vent
Secure Area-Post and Flag
Ventilation
Other
List Other (and their controls)
Special Equipment
Rows
Yes
No
Breathing apparatus- respirator
Escape harness required
Tripod emergency escape unit
Lifelines
Lighting (explosive proof/low voltage)
PPE- goggles, gloves, clothing, etc.
Fire Extinguisher
Other
List Other (and their controls)
Communication Procedure
DO NOT ENTER IF PERMISSABLE ENTRY
LEVELS ARE EXCEEDED
Hazard
Permissable Entry Level
% of Oxygen
19.5% to 23.5%
% of LEL
Less than 10%
Carbon Monoxide
35 PPM (8 hr.)
Hydrogen Sulfide
10 PPM (8 hr.)
Name(s) or Person(s) testing:
Test Instrument(s) used- Include Name, Model, Serial Number and Date Last Calibrated:
Authorized Entrants
Authorized Attendants
PERMIT AUTHORIZATION
I Certify that all actions and conditions necessary for safe entry have been performed
Supervisor Name
First Name
Last Name
Supervisor Email
example@example.com
Signature
DateTime
Submit
Should be Empty: