Confined Space Entry Checklist
To be completed prior to entry.
Case ID
*
Pit Number
1. Site Identification
Site Location
*
Please Select
Nature Strip
Driveway
Footpath
Front Garden
Back Garden
Works Conducted
*
Please Select
C&IP
Vacuum Leak
Block Aid
Refurbishment
Other
Date and time of the Entry
*
-
Day
-
Month
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
2. Isolation
*
Yes
No
Electrical Isolation required ?
Mechanical isolation required?
Contact with system operator required?
Required isolation in place check by
Type Name
3 :Atmospheric Testing Gas/ Recommended Levels
*
PEAK
READING
Oxygen 02 btw 19.5 - 23.5%
Flammables LEL < 5%
Hydrogen Sulphide H2S < 10ppm
Carbon Monoxide CO < 30ppm
Ammonia NH3 < 25ppm
Volatile Organic Compounds VOC < 0ppm
Gas testing performed by continuous Monitoring during occupancy
*
-
Day
-
Month
Year
Gas Detector Calibration date
4: Ventilation
*
Natural
Forced
Spray
Tick the type of ventilation to be used
5: Review of Conditions that may change status of confined space
*
Flow volume
Noise
Traffic
Industrial Weather
Domestic
Select any of the following that will need to be taken into consideration before entry into the confined space.
6: Hot Work
YES
NO
Is Hot work to be performed in the confined space
7: Personal Protection
*
Fall arrest device
Bosun
Eye protection
Lighting
Airline
Boots
Chemical suit
Overalls
Harness
Gloves
Road signage
Fire Ext
Man Cage
Gas Detect Meter
Helmet
2 way radio
Waders
Barricades
First Aid Kit
Lifeline
Platforms
Ladders
Self rescue respirator (less than 5 years old)
Other
8: Personnel Entry
*
Name
Name of Entry person
Houston
Matthew
Josh
Stuart
Kaaren
Stephen
Shane
Other
Other Team
Houston
Matthew
Josh
Stuart
Kaaren
Stephen
Shane
Other
Other Team
Houston
Matthew
Josh
Stuart
Kaaren
Stephen
Shane
Other
9: Emergency Contacts
*
YES
NO
The relevant emergency contacts are accessible onsite
10: Entry Time
*
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
OCC
*
Time phoned in
Control
Contact
Contact CWW for entry time
11: Approval to Enter The confined space described in this entry permit is in my opinion safe to enter using the precautions listed above and all persons are properly trained to perform this work.
*
-
Day
-
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Signature
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