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Confined space permit to work form

Confined space permit to work form

Document confined space hazards, controls, and authorization for safe entry operations.

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

Document confined space hazards, controls, and authorization for safe entry operations.

Use this template
or download pdf

Our confined space permit to work form supports comprehensive hazard control before workers enter potentially dangerous spaces. This digital template captures critical safety information, from atmospheric testing results to personal protective equipment requirements, in one accessible document. If you manage multiple confined spaces across different sites, this template can standardize your entry protocols too as you maintain OSHA compliance.

According to the Bureau of Labor Statistics, confined space incidents claim an average of 129 worker lives annually in the U.S. alone. With our template, you can implement consistent approval processes that prevent unauthorized entry and provide clear emergency response instructions, potentially saving lives at your facility.

Related categories

  • Health and safety management templates
  • Construction templates
  • Facility management templates
  • Risk assessment templates
  • Workplace safety 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
This template was downloaded 12 times

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Related resources

Access a complete set of resources aimed at maximizing safety, quality, and operational excellence, including detailed guides, related templates, and real-world use cases.

Topic guides

Read in-depth guides covering key topics related to this article.

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Template collections

See comprehensive collections of best practice templates related to this topic.

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Use cases

Check out how the Lumiform software can be utilized for related use cases.

Safety Incident Reporting SoftwareSafety management softwarePermit to work softwareEmployee safety app
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Frequently asked questions

Who needs to sign off on a confined space permit to work form?

The confined space entry permit requires signatures from the entry supervisor, the authorized entrants who will work inside the space, and the attendant who monitors from outside. Some organizations also require additional approval from safety managers or department heads before entry.

How can you customize the confined space permit for different types of spaces?

You can customize the template by adding space-specific hazards, adjusting atmospheric testing parameters for unique contaminants, and modifying required PPE sections. Another option is to incorporate your company’s rescue procedures. You can also create separate permit versions for different space categories (tanks, vaults, silos) while maintaining core safety requirements across all permit types.

What are the benefits of using a digital version of this permit form?

The digital format enables real-time approvals, automatic timestamp tracking, required field validation, and instant distribution to all stakeholders. It creates permanent, searchable records and allows photo documentation of hazards or controls. On top of this, it integrates with other safety systems for comprehensive risk management.

How can you use this template to improve confined space safety programs?

You can analyze completed permits to identify recurring hazards, evaluate control measure effectiveness, verify training adequacy, and assess emergency response readiness. The detailed documentation provides valuable data for program improvements, training updates, and demonstrating due diligence during safety audits.


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.
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