close
lumiform
Lumiform Mobile audits & inspections
Get App Get App

OSHA Confined Space Permit Template


Obtaining a confined space entry permit is legally required before allowing workers to enter a tight work zone. This is because working with heavy machinery in a confined space can be exceedingly dangerous if the right safety measures are not taken. However, this template can help you enter the right information so there are no delays in commencing work. In this template, you’ll fill out the following fields:

  • • Required PPE
  • • Rescue procedure plan
  • • CSE communication
  • • Periodic atmospheric test
  • • Entrants
  • • Sueprvisors

It might also be helpful to use a construction scope of work template so that you can obtain all necessary permits before construction work begins.


Downloaded 1 time

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before
  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Register for free on lumiformapp.com and conduct inspections via our mobile app

  • Cut inspection time by 50%
  • Uncover more issues and solve them 4x faster
  • Select from over 4000 expert-proofed templates
Rated 5/5 stars on Capterra

OSHA Confined Space Permit 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

(check name not set)

7.3 CSE Communication

Cell phone

Radio

Rope signals (OATH)

Sound

Verbal

Visual hand signals

Other

(check name not set)

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

Share this template:
This template is also available in:

Similiar templates