Confined Space Entry Permit
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1
2GEORGIA INSTITUTE OF TECHNOLOGY
ENVIRONMENTAL HEALTH AND SAFETY
CONFINED SPACE ENTRY PERMIT
Instructions: This form must be completed by the Georgia Tech Permit Issuer prior to performing any confined space
work on Georgia Tech campus. This permit must remain at the job site until work is completed. After work is completed
the permit should be kept in the project file.
PERMIT MUST REMAIN POSTED AT JOB SITE AT ALL TIMES.
Project Name:
____________________________________________________________________________
Confined Space (description):
____________________________________________________________________________
Location of Confined Space:
____________________________________________________________________________
Purpose of Entry:
____________________________________________________________________________
Date of Entry: ______
Permit Expiration Date:________
Entry Time:_________
Exit Time:_________
Authorized Supervisor:
____________________________________________________________________________
Authorized Attendant(s):
____________________________________________________________________________
Authorized Entrant(s):
____________________________________________________________________________
Hazards Associated with Space
Known Hazards and Special Precautions: _____________________________________________________
TYPES OF HAZARDS
Oxygen-Deficient Atmosphere
Engulfment
Energized Electrical Equipment
Oxygen-Enriched Atmosphere
Toxic Atmosphere
Entrapment
Welding/Cutting
Flammable Atmosphere
Hazardous Chemical
Atmospheric
Engulfment
Energy
Note: Welding/cutting operations requires a Hot Work permit.
Other Permits Required: Y 1
N1 If yes, identify_______________________ Permit Expiration Date: ________
Required Special Precautions
Yes
No
Required Personal Protective Equipment
Yes
No
Lockout/Tagout
Radiation Dosimetry – (e.g. TLD Badge, Pocket)
Purge Area - Flush and Vent
Good Lighting
Secure Area - Post and Barricade
Self-Contained Breathing Apparatus
Mechanical Ventilation
Personal Air Monitor – (Gas Monitor)
Harness
Protective Clothing / Coveralls
Lifeline
Footwear – (Safety Shoes, Boots)
Retrieval Device – Tripod, Cables/Rope
Face / Eye Protection – (Safety Glasses, Face Shield…)
Spark Proof Tools
Hearing Protection
Communication with ENTRANT(S)
x
Gloves
Verbal / Radio
( Circle selection)
Respirator Type:
Communication with Rescue Team
x
Entrant(s) Respirator Trained
Cellular Phone / Phone
( Circle selection)
Entrant(s) Fit Tested
Radio
Fire Extinguisher
RESCUE TEAM
Team Names:
Georgia Tech/ EHS Office
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