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Download Form 17 - Confined Space entry Permit
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CONFINED SPACE ENTRY PERMIT School Logo << School >> PART 1. IDENTIFICATION OF CONFINED SPACE Physical Characteristics A B Sewage pit Workshop welding bay Yes Yes Yes No Yes Yes Yes No Yes No Boiler Yes Yes Yes Yes Yes Yes Description of Space Examples Identified Hazards D E Could the Could the atmosphere have a atmosphere have concentration of a concentration of airborne flammable contaminants that airborne may cause contaminants that impairment, loss of may cause injury consciousness or from fire or asphyxiation? explosion? F Could the atmosphere have a stored free-flowing solid or a rising level of liquid that may cause suffocation or drowning? Yes No Is space enclosed or partially enclosed? C Is space intended or designed primarily for other than human occupancy? Could the atmosphere have oxygen concentrations outside the safe oxygen range? Confined Space = A + B + (C or D or E or F) Is this an enclosed space? Yes No Yes The hazards identified in C to F should be assessed and controlled in Part 2. Risk Assessment. Description of Space: _______________________________________________________________________________________________________________________ Work to be Undertaken: _____________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Entry Point: _______________________________________________________________________________________________________________________________ Can the work be carried out without the need to enter the confined space? Yes / No Page 1 of 4 Form 17 - Confined Space Risk Assessment And Access Record 27/10/10 PART 2. RISK ASSESSMENT This risk assessment must be completed by a competent person who understands the potential hazards and now to control them. Describe how the work will be performed, listing equipment and materials to be used: _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________ Have all possible work methods been considered and the safest one selected? Yes / No In the following table, list all hazards associated with the work method selected, the plant to be used, and any potentially hazardous condition that may exist inside the confined space. For each hazard assess the risk using WI 08 – Risk Management and list the control measures selected following the Hierarchy of Controls. HAZARDS Page 2 of 4 LEVEL OF RISKS Form 17 - Confined Space Risk Assessment And Access Record CONTROLS 27/10/10 ISOLATION The space needs to be isolated from: PERSONAL PROTECTIVE EQUIPMENT The following safety equipment shall be worn: Respiratory protection Harness / lifeline Eye protection Footwear Protective clothing Hearing protection Safety helmet Communication equipment Torch / lighting Other Please tick Yes No Type OTHER PRECAUTIONS REQUIRED Please tick Yes No Type Signage Communication and supervision process Warning notices / barricades Ignition sources (including smoking) banned All persons have been trained Ventilation requirements Emergency response and rescue procedures and equipment Stand-by personnel requirements Atmospheric testing required Atmospheric monitoring required Area cleared of all combustible material Hot Work permitted : Atmospheric monitoring required Other Page 3 of 4 Form 17 - Confined Space Risk Assessment And Access Record 27/10/10 PART 3. AUTHORITY TO ENTER The risk control measures and precautions appropriate for the safe entry and execution of the task in the confined space have been implemented and the persons required to enter the confined space have been advised of and understand the requirements of this written authority: Signed: _________________________________________________________ Date: _______/______/_______ Time: ___________________________ This written authority s valid until: Date: _______/______/_______ Time: ___________________________ PART 4. CONFINED SPACE ACCESS RECORD PERSON REQUIRED TO ENTER CONFINED SPACE I have been advised of and understand the control measures and precautions to be observed with the entry to and work within the confined space. NAME ENTRY DATE EXIT TIME DATE SIGNASTURE TIME PART 5. CANCELLATION OF AUTHORITY TO ENTER All persons and equipment are accounted for : Yes / No Equipment checked and restored correctly: Yes / No Signed: _________________________________________________________ Date: _______/______/_______ Time: ___________________________ Comments: ____________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________ Page 4 of 4 Form 17 - Confined Space Risk Assessment And Access Record 27/10/10
