AMC RISK MANAGEMENT/OHS&E

AMC RISK MANAGEMENT/OHS&E

Confined Space Entry Permit

The contractor or their supervisor is responsible for completing this permit. This permit is valid
only for the date and time specified.
The Manager is responsible for ensuring the permit has been satisfactorily completed prior to
the commencement of entry.
When the entry is complete or this permit expires, the authorised person for the confined
space entry must sign off the permit.
Part A: Authorisation
Permit number:

Date issued:

Authorised person (confined space entry supervisor):

Permit validity: Date of entry

Time of entry

From:

Proposed work to be carried out and location:

Name of person entering confined space:
Name of stand-by person:
Part B: Pre-entry requirements
Requirement
1
2

Yes

N/A

Has a confined space risk assessment

been conducted and a risk control plan
documented?
Are any mechanical, electrical, pipe,
valve or other isolations required?
Specify
For example, pipelines (water, steam or

Issue date: 15/09/10

Issued by: D. Waldron

Issue No: Two

Page 1 of 5
Review: 09/11

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Comment/Action

To:

AMC RISK MANAGEMENT/OHS&E

gas), mechanical or electrical drives,

sludges, deposits, wastes, harmful
materials, electrical services, warning
notices, locks and tags fixes to means of
isolation, radiation and mechanical
services
Have the levels of ventilation and
oxygen/contaminants been checked?

Is ventilation equipment required?

Specify type used

Art toxic gases, solids or liquids present?

Oxygen
Flammable gases
Other

%
%LEL
ppm

AMC RISK MANAGEMENT/OHS&E

Confined Space Entry Permit

Requirement

Issue date: 15/09/10

Issued by: D. Waldron

Yes

Issue No: Two

Page 2 of 5
Review: 09/11

N/A

Comment/Action

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AMC RISK MANAGEMENT/OHS&E

7
8

Is safety equipment or personal

protective equipment required?
Specify PPE to be worn
For example, supplied air respirators,
air purifying respirator, safety
harness, safety protection, foot
protection, protective clothing,
hearing protectors, safety helmets or
communication equipment
Have health assessments of
personnel been conducted?

Is a stand-by person required? Most

work requires nomination of a standby person
Ventilation requirement for purging?

10

Are danger tags or signs displayed?

11

Are the appropriate emergency

procedures or equipment in place
and understood by all parties
entering the work space and standby personnel?
Specify
The conditions for entry are as
marked below:
a)
with supplied air breathing
apparatus
b)
without respiratory protection
c)
with escape unit

12

Part C: Other hazards, precautions or requirements

Requirement

Yes

Warning notices, barricades

Smoking is forbidden

All persons, including the stand-by person,

have attended an accredited course in C.S
entry.

Issue date: 15/09/10

Issued by: D. Waldron

Issue No: Two

Page 3 of 5
Review: 09/11

N/A

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DOCUMENT BECOMES
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Comments

AMC RISK MANAGEMENT/OHS&E

Confined Space Entry Permit

Part D: Authorised person/confined space entry supervisor acceptance
I/We have checked the permits, procedures and isolations required for the safe entry and
execution of the work in the confined space.
Persons entering the confined space are listed below, and will log in/out and will comply with
these, any other reasonable instruction and in accordance with Australian Standard AS
2865:2009. The work area shall be checked and secured on completion of activities.
Name:

________________________________________

Signature:

________________________________________

Date:

________________________________________

Part E: Log in/out

Name

Date

Time in

Time out

Part F: Close out (Authorised contractor)

Name:

Signature:

Date:
Time:

Manager
Permit returned, work completed
Name:

__________________________________________________

Signature:

__________________________________________________

Date:

__________________________________________________

Issue date: 15/09/10

Issued by: D. Waldron

Issue No: Two

Page 4 of 5
Review: 09/11

IF PRINTED THIS
DOCUMENT BECOMES
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AMC RISK MANAGEMENT/OHS&E

File the completed form in the Contractors, Suppliers, Demonstrators and Visitors folder after the
Confined Space Entry Permits tab.
Retain this form on site for two years then archive for a further five years.

Issue date: 15/09/10

Issued by: D. Waldron

Issue No: Two

Page 5 of 5
Review: 09/11

IF PRINTED THIS
DOCUMENT BECOMES
UNCONTROLLED