Confined Space Entry Permit
Download a blank fillable Confined Space Entry Permit in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Confined Space Entry Permit with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2University of Connecticut
Facilities Emergency Procedures:
Canceled permits must be faxed to
Radio/Phone Work Order Control
CONFINED SPACE ENTRY PERMIT
EHS (860-486-1106) within 72
911
(6-3113/6-3114) or
hours of cancellation.
LOCATION & DESCRIPTION
DATE & TIME Issued _____________________
of Confined Space _____________________________________________________________
EXPIRATION____________________________
1
□
□
PURPOSE OF ENTRY _________________________________________________________
Approval for WELDING/CUTTING Y
N
POTENTIAL HAZARDS of Space __________________________________________________________________________
HAZARDS INTRODUCED in Space _________________________________________________________________________________________
DEPARTMENT________________________________________________
ENTRY APPROVER _____________________________________
2
Authorized ENTRANT(S) _________________________________________________________________________________________________
Authorized ATTENDANT(S) _______________________________________________________________________________________________
Required
Completed
Required
Completed
SPECIAL REQUIREMENTS
Y
N
Y
N
Y
N
Y
N
Energy Isolation - Lock Out/De-energize
Retrieval tripod or quadpod and harness
Lines Broken/Capped/Blanked
Lifelines secured to harnesses
Purging – Flushing – Venting of utility lines
Entry/Exit Log (back page)
Space Ventilation (continuous)
Fire Extinguishers (not CO2)
3
Secure area or work zone (Post & Flag)
Special Lighting (e.g., Explosion Proof)
Water pumps
Personal Protective Equipment (list below)
GFCI protection
Means of Communication (indicate below)
Trailing Rope from entrance ________feet req’d
Other: _________________________________
Indicate Energy Sources Isolated:
PPE required above:
□
□
□
□
□
Communication to call Rescue: Radio
Cell Phone
Communication to Entrant: Radio
Verbal
Hand signals
Other____________
Pre-entry Reading
Time during entry – Record readings every 2 hours (8 hours max)
GAS LEVEL TESTS TO
Permissible
Time:
am
am
am
am
am
am
BE TAKEN
Entry
pm
pm
pm
pm
pm
pm
Level
Initials:
Percent Oxygen
19.5% to 23.5%
%
%
%
%
%
%
Percent LEL
Under 10%
%
%
%
%
%
%
4
Carbon Monoxide
Under 35 ppm
ppm
ppm
ppm
ppm
ppm
ppm
Hydrogen Sulfide
Under 10 ppm
ppm
ppm
ppm
ppm
ppm
ppm
Other:
Air monitoring remarks:
GAS MONITORING INSTRUMENTS USED
Model
ID Number
Date Calibrated
Bump Test ( )
5
PERMIT-AUTHORIZING OFFICIAL _______________________________________________
Position________________________________
6
Department __________________________________________________________
Unit ____________ Phone _______________________
All above conditions satisfied:
SIGNATURE of Entry APPROVER _______________________________________________
Date_________________
Time____________
7
Permit CANCELLED by: _______________________________________________________
Date________________
Time__________
8
□
□
□
Reason: Work complete
Rescue unavailable
Conditions in space violate permit
Other____________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal