Templates
Confined space permit to work form

Confined space permit to work form

Obtaining a confined space permit is legally required before allowing workers to enter a tight work zone. This template can help you enter the right information so there are no delays in commencing work.

Use this template
or download pdf
Confined space permit to work form

Obtaining a confined space permit is legally required before allowing workers to enter a tight work zone. This template can help you enter the right information so there are no delays in commencing work.

Use this template
or download pdf

About the Confined space permit to work form

Working in a confined space brings with it numerous safety risks, from hazardous atmospheres to potentially getting trapped. To protect your workers and meet compliance standards, you need a confined space permit to work form.

This template allows you to document critical details, such as atmospheric testing results, safety equipment, and rescue plans, ensuring that every entry is thoroughly assessed and monitored. Using this template will standardize your safety procedures, making it easier for your team to stay compliant and mitigate risks.

When to use a confined space permit to work form

You can use a confined space permit to work form in any situation where workers are entering tight spaces with potential hazards. Common scenarios include maintenance inside storage tanks, cleaning out silos, inspecting underground utility vaults, or performing repairs in large pipelines. In these environments, limited airflow, hazardous gases, or risk of engulfment can make the workspace dangerous, and using the form ensures all precautions are taken.

This form is also essential when working in manholes, septic tanks, or boilers, where entry requires strict adherence to safety protocols. If continuous atmospheric monitoring or emergency rescue equipment is needed, the confined space permit to work form supports you in organizing these details and communicating them clearly to your team.

Best practices in using the confined space permit to work form

Here are some tips for getting the most out of your permit to work form:

  • Perform a full atmospheric test before entry. With this test, you’ll check oxygen levels, toxic gases, and potential flammable atmospheres. It’s critical to conduct these tests with calibrated equipment and record the results on the form to guarantee safe conditions.
  • Document any identified hazards on the form and communicate them clearly to the team. Every confined space can pose unique risks. Once hazards such as toxic gases or potential engulfment are identified, write them down in detail and share this with your team.
  • Rescue plans should be in place before work begins. Use the form to outline rescue procedures and verify if all necessary equipment like harnesses and winches are on site. Your team can then act quickly and safely if an emergency happens.

Download Lumiform’s permit to work form for confined spaces today

Strengthen your safety processes by using our specialized permit to work form. With easy-to-customize fields for hazard identification, atmospheric testing, and rescue planning, this template keeps your team safe while maintaining compliance. You can easily document safety measures, making it perfect for streamlining your workflow.

Categories

  • Risk management and compliance templates
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  • Manufacturing templates
  • Risk assessment templates
Preview of the template
Audit
1.1 Scope
Effective date and time
Expires (date and time)
Permit issued to
Description of work
Location
Specific Location
Is continuous monitoring required?
Serial Number
Most Recent Calibration
Field (fresh air) Calibration
Sensor reading for failure check
2.1 Hazards (check all that apply)
Flammable Atmosphere
Corrosive
Reactive
Toxic
Temperature (>100 degrees F or
Engulfment
Other Hazards
Describe other hazard(s)
3.1 Preparation
Equipment /piping depressurized and vented
Equipment / piping blinded, blanked or disaligned
Power (forced air) ventilation
Electric, hydraulic, pneumatic and mechanical energy sources shut-off and locked out (zero energy state)
Vessel /space steamed, cleaned or washed
4.1 Entry Type
Horizontal
Vertical
5.1 Atmospheric Testing
Air Sample(s)
Time
Oxygen Level (Action Levels: 19.5-23%)
%LEL (if > 10% evaluate for toxicity)
Hydrogen Sulfide (H2S) (PPM)
Carbon Monoxide (CO2)
Temperature
Atmospheric Check after isolation or forced air ventilation
Select date
Oxygen Level (Action Levels: 19.5-23%)
%LEL (if > 10% evaluate for toxicity)
Hydrogen Sulfide (H2S) (PPM)
Carbon Monoxide (CO2)
Temperature
6.1 Protective Equipment
6.2 Protective Equipment (Operational)
Warning signs, barricades
Barricade tape, cones
Ventilation fan or blower
Fire equipment in place
GFCI'S in place
Lighting (hazardous location rated)
Grounding and/or bonding
Ladder
Other
Describe
6.3 Personal Protective Equipment
Airline respirator
SCBA
Other respirator
Gloves
Rain gear
Boots
Hearing protection
Safety glasses
Fall protection/arresting equipment
Chemical splash goggles
Other
Describe
7.1 Rescue Procedures and Equipment
Rescue plan complete
Emergency Number
Location of phone or radio
7.2 Rescue Equipment On Site
Full body harness / lifeline
Rescue winch
Tripod
Other
7.3 CSE Communication
Cell phone
Radio
Rope signals (OATH)
Sound
Verbal
Visual hand signals
Other
Emergency assembly area
Potential emergency situations
Designated Rescue Team
Actions to be taken
8.1 Confined Space Entrants
We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. See entrant employee roster section of the permit for additional signatures. I have been formally trained in CSE.
Confined Space Entrants
Name and Signature (ENTRANT MUST SIGN)
9.1 Confined Space Attendant(s)
I have checked all rescue and communication equipment and reviewed all emergency actions to be taken with authorized entrants. I have been formally trained in CSE.
Name and Signature (ATTENDANT MUST SIGN)
10.1 Confined Space Entry Supervisor
I have complete pr properly evaluated all portions of this permit and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the permit and are adequately trained to perform this task. I have been formally trained in CSE.
Name and Signature (SUPERVISOR MUST SIGN)
Date and time
11.1 Authorized Entrant Roster
Date
We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment, procedures and communication methods.
Entrant Name and Intials
Add signature
Date and time IN
Date and time OUT
12.1 Periodic Atmospheric Tests REQUIRED
Time
Oxygen % (O2)
% LEL
H2S
CO
Initials
13.1 Permit Cancellation
Job completed, high LEL, etc. Provide a brief description
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Frequently asked questions

What is a confined space and why does it require special attention?

A confined space is an area with limited entry and exit points, and it’s not designed for continuous occupancy. It requires special attention because of risks like toxic gases, oxygen deficiency, and restricted movement. Regular monitoring and specific safety protocols are crucial to prevent accidents and keep workers safe.

What are the safety requirements prior to working in a confined space?

Before entering a confined space, conduct a thorough risk assessment. Obtain a permit to work using the template above, verify atmospheric testing, and make sure emergency procedures are in place. It’s essential to train and brief the team on potential hazards and communication protocols to enhance safety and preparedness.

How do I identify potential hazards in a confined space?

To identify hazards, assess the environment for toxic gases, flammable materials, and oxygen levels. Use gas detectors and visual inspections to spot structural risks, and review past incident reports for insights into recurring issues. Additionally, consult safety data sheets to understand any chemical properties present, which can inform you about necessary precautions and protective measures.

How do I maintain proper ventilation in a confined space?

For proper ventilation, use mechanical ventilators or fans to circulate fresh air continuously. Exhaust systems should be working properly to remove contaminants. Test air quality regularly to confirm the absence of harmful gases and adjust ventilation equipment as needed to maintain a safe atmosphere.

Which personal protective equipment is essential for confined space entry?

For confined space entry, essential PPE includes hard hats, gloves, and safety goggles to protect against physical hazards. Depending on the environment, respirators or self-contained breathing apparatus (SCBA) may be required for air quality protection. Check if all equipment fits properly and inspect them regularly for damage.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.