MB Electrical Confined Space Permit
Language
  • English (Canada)
  • French (Canada)
  • Spanish (Latin America)

  • Confined Space Permit

  • Date
     - -
  • Work Site*

  • Assessment of the Potential Confined Space

    Answer these questions to establish the type of confined space
  • Is the space enclosed or partially enclosed?*
  • Was the space designed or intended for continuous human occupancy?*
  • Does the space have a restricted, limited or impeded means of entry or exit?*
  • Does the space contain a hazardous atmosphere?*
  • Are there conditions in the space that present a potential for injury?*
  • Is there an activity being conducted inside or outside the space which may effect the H&S of wokers inside the space?*

  • NOT A CONFINED SPACE

    No permits are required. You do not have to submit this form.

    Be mindful of hazards and completed a hazard assessment.

  • RESTRICTED SPACE

    No confined space permit is required at this time.

    But if conditions change you may need to review and submit again. 

  • CONFINED SPACE

    Continue on to assess the hazard level of the confined space. 

  • Oxygen concentration*
  • Concentration of Explosive or Flammable Gasses*
  • Airborne concentration of toxic substances*

  • Level 3 Confined Space

    1. Confined Space Hazard Assessment
    2. Valid Confined Space Entry Permit
    3. Evacuation Procedure
    4. Valid Rescue Plan
    5. Qualified confined space monitor may be required *

     

    *If hazard assessment determines a confined space monitor is NOT required at the point of entry, a competent worker must be designated to maointian communication with the other workers within the confiend space, and an entry log MUST still be maintained.

  • Level 2 Confined Space

    1. Confined Space Hazard Assessment
    2. Valid Confined Space Entry Permit
    3. Evacuation Procedure
    4. Valid Rescue Plan
    5. Qualified confined space monitor at all times

  • Level 1 Confined Space

    1. Confined Space Hazard Assessment
    2. Supplied breathing air (must be available and worn)
    3. All entrants and monitors trained in pre-inspection and use of supplied air breathing equipment
    4. Qualified confined space monitor in attendance at all times
    5. Valid Confined Space Entry Permit
    6. Evacuation Procedure
    7. Specific Rescue Plan (reviewed and approved by H&S manager)
    8. Qualified confined space monitor at all times

     

    ANY TIME A LEVEL 1 ENTRANCE IS LEFT UNATTENDED THE ENTRANCE MUST BE BARRICADED PHYSICALLY WITH A DANGER DO NO ENTER SIGN HUNG.

     

  • Rows
  • Mechanical Ventilation?*
  • Natural Ventilation only?*
  • Rows
  • Continuous Method of Communication*
  • Rows

  • Confined Space Rescue Plan

  • Means to Summon Rescue*
  • Methods of Rescue*
  • Rescue Equipment Requirements*
  • Medical Equipment*
  • Format: (000) 000-0000.
  • Rows
  • Should be Empty: