Confined Space Permit To Work (With Checklist)

GENERAL INFORMATION

Company:

Location (Specify Area / Attach Layout Plan)

Area to be entered:

Purpose for entry:

Tool to be used:

Special Instructions:

Start Date & Time:

End Date & Time:

Remarks (if any):

Checklist

1. Has risk assessment conducted for the scope of work to be carried out in the confined space?

If NO, state reason

2. Have you personally checked the area to be entered?

If NO, state reason

3. Has the area been cleaned and purged of water, oil and other chemicals?

If NO, state reason

4. A gas test is required before this permit can be approved and issued.

Gas Test Result Attached & Endorsed By Confined Space Safety Assessor

If NO, state reason

5. Is hot work being carried out in the confined space?

Attach Hot Work Permit

If NO, state reason

6. Are electrical circuits de-energised and their breakers/ switches locked tagged?

If NO, state reason

7. Is ventilation installed?

If NO, state reason

8. Is blower / exhaust fan installed and has it been commissioned?

If NO, state reason

9. Is lighting installed and is it adequate?

If NO, state reason

10 Is first aid facilities available?

If NO, state reason

11. Are surrounding conditions including atmosphere and wind direction such as to permit safe entry of the area?

If NO, state reason

12. Protective equipment to be used (Tick for items required):

If Other, please state

13. I have checked the above area & am satisfied that entry into the confined space is safe. I understand all safety precautions to be taken under current legislation & all persons involved are informed of the hazards when working in confined space by TBM

Verified by SafetyAssessor/WSHO / WSHC / Engineer/ Work Supervisor)

14. I verified that the abovementioned area has been checked and in circumstances noted, I am satisfied that work and entry into the confined space at this area is safe.

Approval by PM or Competent Person: CM/ Site Manager

15. Permission is hereby granted to bearer of this permit to entry the confined space at the abovementioned area.

If Permit is Revoked, please provide reason (where necessary)

Work in Confined Space Checklist (If Required)

Trade

Inspected By:

A. Permit Space Hazard

Indicate The Specific Hazard

Gas Monitoring

Date & Time	Oxygen (less than 19.5% or greater than 23.5%)	Flammable gases or vapours (> 10% Of LEL)	Carbon Monoxide (less than 25 ppm)
-	-	-	-

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If Others, Please state:

B. Equipment Required For Entry And Work Specify As Required

1. Personal Protective Equipment

2. Atmospheric Testing

3. Communication

4. Rescue Equipment

If Others, Please state:

C. Preparation For Entry After

1. Isolation Methods

If Others, Please state:

2. Name of Man-hole Supervisor / Confined Space Safety Assessor

3. Name Hole Watch Attendant

4. SOC (Manhole) Name List

SOC (Manhole) Name List
-

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5. Additional Permits (Required Or Attached)

If Others, Please state:

D. General Items Check

General Items Check

D. General Items Check	Yes or No	If NO, State Reason
-	-	-

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E. Atmospheric Testing / Monitoring Equipment

Equipment Name / Type :

Serial No :

Usage Range :

Usage Tolerance :

Last Calibrated (Date) :

F. Manhole Supervisor Monitoring Report

Date

Record Monitoring Results Every (Hours)

Manhole Supervisor Monitoring Report

Results___ hrs	Testing	If Other, Please state	Acceptable Condition
-	-	-	-

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WORKER’S CONFINED SPACE TIME-IN / TIME-OUT RECORD

SR/NO	NAME	NRIC/FIN	TIME-IN	TIME-OUT	REMARKS
-	-	-	-	-	-

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Checked By:

Signature

Date