MM slash DD slash YYYY
Start Time
:
Finish Time
:
(not to exceed 1 shift)

Space Preparation

Max. file size: 2 GB.
Drained, Flushed, Cleared
Chemical Lines Isolated
Neutralized
Natural Gas Lines Isolated
Purged
Steam Lines Isolated
Lock Out Tag Out
Water Lines Isolated
Area Secured/Barricaded
MM slash DD slash YYYY
Time
:

What additional hazards potentially exist due to the specific work to be performed: (Check either YES or NO to each)

(For each item marked “YES”, a specific method to eliminate/isolate/control must be implemented.)
Flammable
Excavation/Trenching
Welding/Burning
Toxics
Gases/Fumes
Leakage (liquid, gas, solid)
Electrical Tools (GFCI Needed)
Chemical/Corrosive/Acids
Heat
Hydraulic Loss/Stored Energy
Steam/Thermal
Moving Parts
Radiation/Lasers
Adjacent Activities
Adjacent Overhead Cranes
Hazardous Entrance/Exit
High Voltage
Hot Work
Air/Pneumatic
Line Breaking
Gravity/Overhead Hazards
Other
Fall Hazards
I have reviewed and addressed all safety/health requirements on the Permit and also on the Specific Confined Space procedures for this entry space:
Clear Signature
MM slash DD slash YYYY
Authorized Entrant
Names
Initial Prior to Starting Job
Initial When Finished Job
 
Authorized Attendant
Names
Initial Prior to Starting Job
Initial When Finished Job
 
Acceptable entry conditions. Record continuous monitoring results every 2 hours minimum.
TIME
OXYGEN (20.9%)
LEL (0%)
CO (0 PPM)
H2S (0 PPM)
OTHER
Meter Reading
 
MM slash DD slash YYYY
Communication Style
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