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Confined Space Permit

Author: Novade Solutions

Published on: 7/6/2022


Confined Space Permit

General Information

Applicant Name
Company
Valid From
Valid Until
Work Description
Work Location

*Work Location Photo


Items to Check

*1. Ventilation & lightings are provided and adequate. (and dedicated spotter/s if applicable)

*2. All personnel carrying out work in confined space are competent with relevant required training competency, such as CCSA, Manhole Supervisor, and Manhole Worker where applicable.

*3.Confined space attendant has been appointed and assigned at entrance

a. Confined Space Attendant Name
b. Confined Space Attendant Contact No

*4. Proper use of PPE provided - safety harness, lifeline, respiratory protection, etc

*5. Appropriate signage posted at the entrance and an attendance signboard provided

*6. Area intended to work had been purged and flushed thoroughly before commencement of work.

*7. Safe means of access/egress into the confined space provided

*8. Electrical tools of flame-proof and approved types

*9. Sufficient supplies of rescue equipment provided / made readily available and properly maintained

Gas Test Reading

Date & Time of Gas Test
Date & Time of Gas Test
Gas Meter Serial No
% of Oxygen [19.5% - 23.5%]
% LEL [<10%]
Carbon Monoxide [<25ppm]
Hydrogen Sulphide [10ppm]
Confined Space Assessor Remarks
Applicant Remarks
Endorser Remarks
Approval Remarks

Confined Space Permit

General Information

Applicant Name
Company
Valid From
Valid Until
Work Description
Work Location

*Work Location Photo


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Confined Space Permit

Author: Novade Solutions • Published on: 7/6/2022

Web Preview
Confined Space Permit

General Information

Applicant Name
Company
Valid From
Valid Until
Work Description
Work Location

*Work Location Photo


Items to Check

*1. Ventilation & lightings are provided and adequate. (and dedicated spotter/s if applicable)

*2. All personnel carrying out work in confined space are competent with relevant required training competency, such as CCSA, Manhole Supervisor, and Manhole Worker where applicable.

*3.Confined space attendant has been appointed and assigned at entrance

a. Confined Space Attendant Name
b. Confined Space Attendant Contact No

*4. Proper use of PPE provided - safety harness, lifeline, respiratory protection, etc

*5. Appropriate signage posted at the entrance and an attendance signboard provided

*6. Area intended to work had been purged and flushed thoroughly before commencement of work.

*7. Safe means of access/egress into the confined space provided

*8. Electrical tools of flame-proof and approved types

*9. Sufficient supplies of rescue equipment provided / made readily available and properly maintained

Gas Test Reading

Date & Time of Gas Test
Date & Time of Gas Test
Gas Meter Serial No
% of Oxygen [19.5% - 23.5%]
% LEL [<10%]
Carbon Monoxide [<25ppm]
Hydrogen Sulphide [10ppm]
Confined Space Assessor Remarks
Applicant Remarks
Endorser Remarks
Approval Remarks
Mobile Preview

Confined Space Permit

General Information

Applicant Name
Company
Valid From
Valid Until
Work Description
Work Location

*Work Location Photo


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