Confined Space Entry Permit

The space, its hazards, how they are isolated and equipped, and the atmosphere before entry.

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Project

Job No.

Client

Sheet ____ of ____

Permit No.

Date

Valid From (time)

Valid To (time)

Space ID / Description

Location

Contractor / Crew

Purpose of Entry / Work to be Done

Space Classification

Permit-required confined spaceNon-permit confined spaceAlternate entry proceduresReclassified — hazards eliminated

Hazards Identified

Oxygen deficiencyOxygen enrichmentFlammable atmosphereToxic atmosphere (H₂S, CO)EngulfmentEntrapment / converging wallsMechanicalElectricalThermal / heat stressChemical / corrosiveNoiseSlips, trips, fallsResidual product / sludgeHot work inside the space

Isolation & Control Applied

Lockout / tagoutBlinds / blanks fittedDouble block & bleedLines disconnected / misalignedDrained, flushed, purgedMechanical drives lockedElectrical isolated & taggedSpace secured against entry

Time	O₂ %	LEL %	CO ppm	H₂S ppm	Other (specify)	Tested By (initials)

Acceptable entry conditions: oxygen 19.5–23.5%, flammable vapour below 10% LEL, CO below 25 ppm, H₂S below 10 ppm — or the stricter site limit. Test in this order: oxygen, then flammable, then toxic. Test every level of the space, top to bottom, before anyone enters. If any reading goes out of limits, everyone leaves and the permit is void.

Instrument Make / Model

Serial No.

Calibration Date

Bump Test Before Use

YesNo

Continuous Monitoring

YesNo

Re-test Interval

Ventilation

NaturalMechanicalNone

Purge / Ventilation Duration

PPE & Entry Equipment

Hard hatSafety glassesGlovesFR clothingFull body harnessRetrieval lineTripod / davit & winchPersonal gas monitorSCBA / supplied airEscape respiratorLow-voltage / GFCI lightingIntrinsically safe toolsBarricades & signageFire extinguisher

HP-CS-01 | Rev 0 | Side 1 of 2 Free blank form from HOT PASS QA/QC — hotpassqc.com

Confined Space Entry Permit

Who went in and came out, rescue arrangements, the pre-entry check and closure.

HOT PASS QA/QC Document Control
hotpassqc.com

Project

Job No.

Client

Permit No.

#	Entrant Name (print)	Company	Time In	Time Out	Time In	Time Out
1
2
3
4
5
6
7
8

The attendant keeps this list current. Nobody is inside who is not signed in, and the permit does not close until every line has a time out.

Attendant(s) — name

Entry Supervisor — name

Communication Method

Rescue — arranged before entry, not after

Rescue Service

Contact / Phone

Means of Summoning

On Site / Standing By

YesNo

Rescue Service Confirmed Available

YesNo

Retrieval System In Use

YesNo

If no retrieval system, why

#	Pre-entry check — before the first entrant goes in	Yes	No	N/A
1	Entrants, attendant and supervisor trained for this space and briefed
2	All isolations verified at the point of isolation, not on paper
3	Atmosphere tested and within limits at every level of the space
4	Ventilation running and will stay running throughout the entry
5	Attendant is at the opening, has no other duties, and can count everyone inside
6	Communication tested between entrants and attendant
7	Retrieval equipment rigged and attached before entry
8	Openings guarded; unauthorised entry prevented
9	Hot work permit raised where hot work is done inside the space
10	Evacuation signal agreed, and everyone knows it means leave immediately

Entry supervisor — permit authorised / Date & Time

Attendant / Date & Time

Entrant representative / Date & Time

Closure — the permit is not complete until this is signed

Entry Complete (time)

All Entrants Accounted For

YesNo

Space Secured By

Permit Cancelled (time)

Tools, Equipment & Materials Removed

YesNo

Reason for Cancellation (if not normal completion)

HP-CS-01 | Rev 0 | Side 2 of 2 Free blank form from HOT PASS QA/QC — hotpassqc.com