Equipment/ Vessel Confined Space ID: Entry Date:

# Requirement Yes N/A

1 Confined space entry procedures/ instructions provided and available
2 Area barricade and has warning signs posted
3 Electrical source isolated
4 Process piping/equipment's isolated
5 Hydraulic / pneumatic and other energy sources isolated
6 Lockout and hold tag procedure followed
7 Hot/cold work permit completed
8 Confined space entry permit completed
9 Atmosphere tested for % oxygen (O2)
1 Atmosphere tested for % LEL
0
1 Atmosphere tested for hydrogen sulfide (H2S)
1
1 Atmosphere tested for other gases (e.g. CO), identify
2
1 Gases/chemicals purged, flushed, vented
3
1 Continuous gas testing performed
4
1 Mechanical ventilation provided
5
1 Appropriate personal protective equipment(PPE) provided and used
6
1 Appropriate respirator (s) (e.g. SCBAs) provided and used
7
1 Full-body harness provided and used by each entrant
8
1 Appropriate lighting equipment provided
9
2 Rescue service notified of confined space entry operations
0
2 Rescue equipment (e.g. hoist) available
1
2 Fire extinguisher available at designated entry point
2
2 Standby man continuously present during confined space entry
3
2 Standby man has necessary PPE
4
 2 Communications equipment for stand by man and entrants provided
5
2 Entry log sheet available at designated entry points and used
6

Signatur
Name Badge# Date/Time
e
CSE Supervisor
Site Supervisor
Note: This checklist shall be completed by the Confined Space Entry Supervisor and signed & acknowledge by Site
supervision during their joint site inspection before allowing confined space entry. The completed checklist shall remain
with the Confined Space Standby Man on site after the joint site inspection is complete.
* Checklist to be kept for 3 months with the work permit.

Form HSI-042-05 Rev. 2 Dated 01.01.2022