6630215 - Confined Space Entry Checklist and Permit

  • Confined Space Entry Checklist and Permit

    The HSEOP-13-01, Confined Space Entry Checklist and Permit, must be completed prior to any permit required confined space entry. The purpose of this form is to verify that all health and safety considerations have been addressed prior to entry. Present and previous contaminants contained in the confined space must be listed on this permit form.

  • The confined entry permit cannot be completed until all testing and sampling has been accomplished. This means that it must be filled out at the site. This form is to be signed by all entrants and attendants. The confined entry permit is not valid without the signature of an authorized entry supervisor.

  • Section 1 - General Information:

  • Date:*
     - -

  • Section 2 - Hazard Assessment:

  • A. Attended Confined Space Entry Training?*
  • B. Nature of Work*
  • Has an SDS been obtained for each chemical in the previous question?*

  • D. Pre-entry atmospheric monitoring

  • E. Identify Other Potential Hazards

  • Vehicle traffic*
  • Pedestrian traffic*
  • Structural integrity & collapse*
  • Pressurized equipment (hydraulics, pneumatics, etc.)*
  • Mechanical equipment*
  • Electrical hazards*
  • Entanglement*
  • Air quality not maintained without ventilation*
  • Influx of liquid (engulfment)*
  • Chemical exposures and corrosives*
  • Adequate lighting*
  • Flammable or combustible material*
  • Falls*
  • Slippery surfaces*
  • Dangerous insects (i.e. centipedes)*
  • Dangerous animals (i.e. snakes)*
  • Biohazards*
  • Sharp objects*
  • Poor communication*
  • Welding hazards*
  • Non-ionizing radiation (radio waves, microwaves, etc.)*
  • Noise*
  • Dangerously hot or cold surfaces*
  • High temperatures*
  • Low temperatures*

  • F. Identify Controls Needed

  • All entries require the following*
  • Vehicle barricades, flagger in place*
  • Pedestrian barricades, signage in place*
  • Shoring, bracing, securing in place*
  • Lockout and tagout implemented*
  • GFCI used for corded electrical equipment*
  • Inert gas purge*
  • Mechanical air ventilation*
  • Continuous air monitoring*
  • SCBA or supplied air rescue for rescue*
  • Long sleeves/pants*
  • Eye wash*
  • Battery powered lighting or lighting is GFCI protected*
  • Hot work permit completed*
  • Fire extinguisher present for hot work*
  • Instrinsically safe lighting supplied for hot work*
  • Guardrail around opening or other fall protection provided (if greater than 6 ft.)*
  • Housekeeping acceptable*
  • Control insects*
  • Control animals*
  • Two-way communication equipment*
  • Welding controls in place (FR clothing, welding shield, respirator)*
  • Shielding*
  • Hearing protection*
  • Guarding on tools in place*
  • Heat stress controls (take lost of breaks, water, shade etc.)*
  • H. Hot Work Permit Completed and signed?*

  • Section 3 - Permit Determination

  • Based on the hazard assessment above, decide what kind of space this qualifies as

  • Section 4 - Emergency Planning

  • Emergency extraction over 1.5m (5 feet) deep?*

  • Non Entry Rescue (Preferred Choice)

  • Harnesses worn?*
  • Lifelines attached?*
  • Mechanical extraction devices present? (ex. tripod)*
  • Attendants instructed to call emergency services and attempt a non-entry rescue only*

  • Entry Rescue

  • Entry Rescue required?*

  • Section 5 - Pre-Job Meeting

  • List all personnel authorized to enter the space

  • 1. c) Has this person been trained in confined space?
  • 2. c) Has this person been trained in confined space?
  • 3. c) Has this person been trained in confined space?
  • 4. c) Has this person been trained in confined space?
  • 5. c) Has this person been trained in confined space?
  • 6. c) Has this person been trained in confined space?

  • Additionally, sections 7 (ongoing atmospheric testing) and sections 8 (sign-in and out log) must be posted outside the work area and completed as required.

  • Should be Empty: