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Working In Confined Space Checklist

Author: Novade Solutions

Use this checklist template to maintain safety when working in confined space.

Published on: 11/14/2024

Working In Confined Space Checklist

Permit-To-Work - Work In Confined Space Checklist

Contractor

Client

Trade

Inspected By:

A. Permit Space Hazard

Indicate The Specific Hazard

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 of Hole Watch Attendant

4. SOC (Manhole) Name List

SOC (Manhole) Name List
-

Edit Table

5. Additional Permits (Required Or Attached)

If Others, please state

D. General Items Check

General Items Check

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

Edit Table

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 Others, Please State	Acceptable Conditions
-	-	-	-

Edit Table

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

SR/ NO	NAME	ID No.	TIME-IN	TIME-OUT	REMARKS
-	-	-	-	-	-

Edit Table

Checked By:

Signature

Date

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Working In Confined Space Checklist

Permit-To-Work - Work In Confined Space Checklist

Contractor

Client

Trade

Inspected By:

A. Permit Space Hazard

Indicate The Specific Hazard

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 of Hole Watch Attendant

4. SOC (Manhole) Name List

SOC (Manhole) Name List
-

+ Add New Row

5. Additional Permits (Required Or Attached)

If Others, please state

D. General Items Check

General Items Check

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

+ Add New Row

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 Others, Please State	Acceptable Conditions
-	-	-	-

+ Add New Row

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

SR/ NO	NAME	ID No.	TIME-IN	TIME-OUT	REMARKS
-	-	-	-	-	-

+ Add New Row

Checked By:

Signature

Date

Ensure safety and compliance with Novade Lite’s Working in Confined Space Checklist, designed to assess hazards, verify procedures, and protect workers in confined space operations