GO DIGITAL TODAY

Convert your paper

checklists into digital forms
Scan this QR code to use this
paper checklist on your
smartphone or tablet. Visit
www.iauditor.com

General Details

Purpose of Entry

Enter text

Communication Procedures

Visual Life line Voice Contact Radio Signal

Other

Rescue Procedures

Click + to add rescue procedures

Procedure
Enter details here

Enter text

Pre-Work

Indicate whether the following items are completed and reviewed before entry

Lockout/Deenergize/Tagout

Yes No N/A

Line(s) Broken-Capped-Blank

Yes No N/A

Purge-Flush and Vent

Yes No N/A
Ventilation

Yes No N/A

Secure Area (Post and Flag)

Yes No N/A

Breathing Apparatus

Yes No N/A

Resuscitator - Inhalator

Yes No N/A

Standby Safety Personnel

Yes No N/A

Full Body Harness Body with D ring

Yes No N/A

Emergency Escape Retrieval Equipment

Yes No N/A
Lifelines

Yes No N/A

Fire Extinguishers

Yes No N/A

Lighting (Explosive Proof)

Yes No N/A

PPE

Yes No N/A

Respirators (Air Purifying)

Yes No N/A

Hot Work Permit (Buring and Welding)

Yes No N/A

Completion

Click + to add names of people involved

 Person

Full Name, Signature and Position of Person Involved

(e.g. Sheen Meyer - Entrant)


Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things,
workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to
determine if the use of such checklist is permissible in your workplace or jurisdiction.