CONFINED SPACE ENTRY PERMIT CONTRACT No.

PERMIT No.
To be revalidated by gas test
PROJECT/ SITE

ALL WORK UNDER THIS PERMIT IS VALID FOR A SINGLE ACTIVITY AND PER SHIFT
REQUESTED BY (Supervisor) DATE & TIME DURATION

CONTRACTOR
SPECIFIC WORK LOCATION

DESCRIPTION OF WORK &

HAZARDS (Include nature of Confined
space E.g. Manholes, tanks etc.)

EQUIPMENT IDENTIFICATION. E.g.

Tools, Rescue equipment, gas tester,
ventilation system, lighting etc.
NOTE: All equipment used inside the
confined space must be "intrinsically
safe".

Requirement Yes No N/A Requirement Yes No N/A

Space monitoring reading taken & recorded Entrants are trained on Entry & Rescue by 3rd Party

Lock-out/ De-energise Entrants are medically fit.

Purge/ flush/ drain required Trained attendant is provided. Name

PRE ENTRY REQUIREMENT (Must be
completed by Supervisor and verified on Ventilation (Natural/ mechanical) Rescue equipment (Tripod, lifeline) at location
site by Permit Authoriser)
Lighting provided is intrinsically safe Respiratory equipment & type

Any other Permit required? E.g. Hot work Entrants are briefed on activity and PTW requirement.

Signage provided

Before Entry Readings 2nd Test Readings 3rd Test Readings

Time: Time: Time:

ATMOSPHERIC MONITORING Permissible Entry Levels Signature: Signature: Signature:
(Frequency must be as per PTW
Procedures but less than 4hrs) Must be
Oxygen 19.5% - 23.5%
carried out by trained person using a
calibrated gas tester.
Combustible/ Flammable gas (E.g. Hydrogen) Less than 10%

Other toxic gases

ISSUE

I ….Supervisor …………………………(Permit requestor) confirm that this Confined space entry Permit to Work requirement have been checked and recorded at work location.
_______________________
I will ensure all operatives are briefed on Permit to Work requirements and the activity.
Signature, Date & Time

I ……..Site/ Construction/ Project Manager …. (PTW Authoriser) confirm to authorise the activity in confined space to be carried out as detailed in this Permit.
_______________________
I confirm that I have physically checked work location and all Permit to Work conditions is satisfactory.
Signature, Date & Time

HAND-BACK/ CLOSE OUT (Must be completed by Supervisor/ Permit requestor and returned to Permit Coordinator)

Work is completed at (Time & Date): ………………….

All equipment has been stored correctly.

I ….Supervisor…………………………(Permit requestor) confirm that the work is completed and have checked that confined space is free of any materials/ persons and well secured to prevent entry to _______________________
unauthorised persons. Signature, Date & Time

SUSPENSION/ CANCELLATION
Where monitoring of any type identifies contractor works which are not adequately covered by a Health and Safety MS/RA, all or specific parts of those works will be immediately suspended by the Supervision Consultant and/or the Employer until
satisfactory action is taken by the contractor to rectify the situation.
Conditions observed for suspension/ Cancellation of Permit:

NAME: ……………………………. SIGNATURE .............................................. DATE .................................

SOP-355 ATT. 7.8 Rev 5