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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.

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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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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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