Confined Space Work Permit

Project Name: Permit No: CSWP/_____________

Contractor's Name: Date : ______ /______ /____________
Supervisor's Name: Permit Start Time: AM / PM

Contact Number: Permit End Time: AM / PM

Location of Work: Number of Workers Engaged:

Description on the activity to be Performed and plants to be used :

Has Rescue services Name of Rescue Person Contact no.

been informed, if Yes? Name of Rescue Person Contact no.
Hazard Management in the confined space.(The following processes within the confined space have been withdrawn from service.)
Electrical power Yes No Pressure systems Yes No
Mechanical power Yes No Liquids/flowing substances Yes No
flammable substances Yes No ingress/presence of liquids Yes No
oxygen enrichment/deficiency Yes No solids that can flow Yes No
toxic gases, fumes or vapours Yes No excessive heat or cold Yes No
Safe systems
A written safe work method statement and risk assessment is available and approved for this activity. Yes No
if Yes, The confined space has been assessed and the following control measures, are identified in the written safe method of work with analysing
of the risk and remedial measures identified for implementation. (click all that apply).
Removal of residues Safety harnesses / lifelines Warning signs / locks or tags in place
Use of intrinsically safe tools Full breathing apparatus (BA) System of communication in place (e.g.
Purge atmosphere before entry Escape BA only radios/mobiles)
Forced ventilation/extraction First aid/emergency Competency of work team checked
Tools and equipment checked
Team leader and rescue team
for safe use
DESCRIPTION OF RISK Yes / No COMMENTS & ACTIONS
1 Are all those entering the confined space trained and competent?

2 Is the correct PPE identified on the risk assessment, readily available and fit for use?

3 Is there adequate access and egress?

4 Is an emergency rescue plan and rescue equipment in place as approved?

5 Has the rescue team been trained in the use of rescue equipment?

6 Has a system of communication been established & emergency contact nos available?

7 Is there a requirement for forced ventilation to be in place? If so, what type?

8 Has the atmosphere been monitored prior to entry and has the results recorded?

9 Has the monitoring equipment been calibrated?

Is the monitoring equipment capable of detecting gases, lack of oxygen or flammable
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atmospheres, etc.?
Have all those entering the space been briefed on the monitoring equipment and what to
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do in the event of an emergency?
12 Have all possible harmful substances been removed from space?
Have all services to the space been isolated or disconnected? If so, who is responsible for
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continued isolation?
14 Is breathing apparatus required? If so, what type and is it EHS approved?

15 If breathing apparatus is required, are all persons competent in its use?

16 If breathing apparatus is to be used have those entering been face-fit tested?

17 Are all the necessary signs and barriers available?

18 Is intrinsically safe task lighting available?

19 Are any other permits required (such as hot works etc.)?

CONTRACTOR AUTHORISED PERSON (i.e.Site Eng. / Supervisor) - (PERMIT GENERATOR )
Requesting and confirming by contractor’s representative: As the engineer/supervisor, I am familiar with the scope of work and safe
systems to be implemented. I confirm that the precautions specified above are complied with and the persons carrying out the work are fully
briefed on the safe method of work.

Name Signature Date

COLLIERS REPRESENTATIVE With CONTRACTOR COMPETENT PERSON (i.e.Site Eng. / Manager) - (PERMIT ISSUER)

Confirmation: I understand and certify that the precautions are adopted / not adapted for Permission
carrying out the confined work as per the above checkpoints and according to the approved
SWMS for the activity. GRANTED DECLINED
IF DECLINED, ACTION REQUIRED BY CONTRACTOR WITH AGREED TIME LINE:

ACTION COMPLETED - APPROVAL GRANTED

Name Signature Date

Name Signature Date

Note: -
1. The completed permit is to be hanging adjacent to the work being carried out along with a copy of the SWMS of the activity.
2. The work cannot be allowed if the permit is not signed by an Authorised person.
3. This work permit must be completed by the work supervisor and then be reviewed & signed by a Colliers representative.
4. Surrender the permit copy to the office after onle the job com