Hsw Handbook Confined Space Entry Permit

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HSW Handbook
CONFINED SPACE ENTRY PERMIT (Template)
Please tick/check the boxes to indicate completion. To be displayed, or readily locatable in the work area for the duration of the task.
Period of time work will
Date
/
/
Time
am/pm
be carried out in the
confined space
School/Branch
Exact location of work
(include building, room/space no)
Description of work
Risk assessment (RA)/Job safety
Control measures for all hazards identified on the risk assessment
analysis (JSA)/Safety management
Emergency control plan
plan. (SMP) completed & includes
Communication methods
Name(s) of worker(s) authorised to
Worker 1
Worker 2
enter the space
Name
Name
Worker(s) entering the space:
have a record of competency
held on file
Yes - Date of training
/
/
Yes - Date of training
/
/
No (If no – arrange training prior to
No (If no – arrange training prior to entry)
entry)
have been provided with
Yes
(RA/JSA/SMP signed)
Yes
(RA/JSA/SMP signed)
information and instruction based
on the RA/JSA/SMP
Standby person(s) has/have been
nominated for the duration of this task
and have received information on their
Name:
Name:
role/responsibilities
Isolation checklist (as applicable)
The confined space has been isolated from the following
Water
Gas
Steam
Mechanical/electrical devices
Auto fire extinguishing systems
Hydraulic/electric/gas/power
Deposits/wastes
Locks and/or tags are in position
Atmosphere monitoring
Has been tested and levels safe
Oxygen
%
(Please insert name of gas as applicable
(or respiratory protection provided)
Flammable gases
%
e.g. CO
2,
H2S etc)
Other gases
%
%
%
Other airborne contaminants
Worker(s) provided with air breathing apparatus
Worker(s) is working without respiratory protection
Hot work (if applicable)
Is permitted and area clear of all combustibles and fire protection equipment available
Respiratory protection
Footwear
Harness/lifelines
Hearing protection
Personal protective equipment
Eye protection
Helmet
provided
Hand protection
Communication equipment
Protective clothing
Other
Warning notices/barricades
In place
AUTHORITY TO ENTER
The control measures and precautions appropriate for the safe entry and execution of the work in the confined space have been implemented and persons
required to work in the confined space have been advised of and understand the requirements of this written authority.
Signed (person in direct control)
Date
Time
Name of person in direct control)
This written authority is valid until
Date
Time
WORKERS LEFT THE SPACE
Worker(1): Signature
Time
Worker(2): Signature
Time
Return the completed confined space entry permit to the person authorising the activity, for record keeping purposes.
HSW Handbook
Confined Spaces
Effective Date:
23 April 2015
Version 2.0
Authorised by
Associate Director, HR Policy, Safety and Compliance
Review Date:
23 April 2018
Page 1 of 1
Warning
This process is uncontrolled when printed. The current version of this document is available on the HSW Website.

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