Confined Space Entry Permit Form
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1
2Indiana University Permit-Required Confined Space Entry Permit
A. Space Description
1. Type of confined space ______________________________________________________________
6. Start Date _________________
2. ID #__________________________________________________________________________________
3. Location_______________________________________________________________________________
7. Start Time _________________a.m./p.m.
4. Entry Purpose_________________________________________________________________________
8. Scheduled Expiration_________a.m./p.m.
5. Hazard Identification_____________________________________________________________________
B. Personnel
The following person(s) trained in confined space procedures are assigned work in connection with a confined space entry, in accordance with this permit:
9. Entrants:
Name (Printed)
Name (Printed)
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
10. Attendants:
Name (Printed)
Name (Printed)
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
C. Type of Entry
11. Permit-Required Confined Space (See Section G)
12. Alternate entry
a.
_____All employees trained
b.
_____Atmospheric hazard (identify)_____________________________________________________________________________
c.
_____Atmospheric data available
d.
_____Ventilation and monitoring without entry
e.
_____Space atmosphere tested/no hazardous atmosphere
f.
_____Continuous ventilation during entry
g.
_____Continuous monitoring during entry
13. Reclassify space from Permit to Non-permit
a.
_____No atmospheric hazard present
b.
_____All other hazards eliminated before entry (list)_________________________________________________________________
_________________________________________________________________
_______________________________________________
Signature of Entry Supervisor
D. Safety Requirements
Yes
No
Date/Time
Checked By
14. Area secured______________________________________________
____
____
___________
__________________________________
15. Piping disconnected________________________________________
____
____
___________
__________________________________
16. Energy sources and mechanical hazards locked/tagged out_________
____
____
___________
__________________________________
17. Cleaning (flushing/washing) done_____________________________
____
____
___________
__________________________________
18. Required purging or venting done_____________________________
____
____
___________
__________________________________
19. Sources of ignition controlled_________________________________
____
____
___________
__________________________________
20. Cutting, welding permit obtained______________________________
____
____
___________
__________________________________
21. Use of hazardous or flammable materials approved_______________
____
____
___________
__________________________________
22. Other____________________________________________________
____
____
___________
__________________________________
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