Non-Permit Required Confined Space Entry Permit

Non-Permit Required Confined Space Entry Permit
Permit Status

OpenClosedCancelled
Date

MonthDayYear
Date
Entry Supervisor

First NameLast Name
Supervisor Email
example@example.com
Authorized Entrant(s)
Authorized Attendant(s)
Project Name
Did you complete a paper Permit for this job?

YesNo
Take a photo of the paper permit

Take Photo/Share File

Cancelof
Location of Entry
Vessel Name
Reason for Entry
Expected Duration of Entry
Note times in hours
Atmospheric Test Results
% of Oxygen (allowable level 19.5% to 23.5%):
% LEL (allowable level 0%):
Carbon Monoxide (allowable level 0%)
Hydrogen Sulfide (allowable level 0%)
Confined Space Evaluation
1. Is the gas monitor current on calibrations

YesNo
2. Are test readings within the "Allowable Level"

YesNo
3. Is there a material that can engulf the entrant

YesNo
4. Could entrant be trapped, crushed or smothered

YesNo
5. Are there any additional uncontrolled safety hazards present

YesNo
6. Can the space be maintained as safe during work

YesNo
7. Are the entrants properly trained

YesNo
8. Are rescue procedures and equipment available if necessary

YesNo
9. Are attendants rotated every two hours

YesNo
*STOP*

Based on the above answers you provided, a Confined Space Entry Permit IS required. Please proceed with your plan by first meeting all the requirements of the Confined Space Entry Permit.
PROCEED

Based on the above answers you provided, a Confined Space Entry Permit is not required. Please proceed with your work. If conditions change or hazards arise, this permit must be cancelled and the approval process must start again.
Acceptance
Entrant Acceptance (Lead)
Type Name
Attendant Acceptance
Type Name
Entry Supervisor Acceptance
Type Name
Should be Empty:

Non-Permit Required Confined Space Entry Permit

Atmospheric Test Results

Confined Space Evaluation

Acceptance