Free Confined Space Entry Permit HR Template
Confined Space Entry Permit
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Permit Number: |
CS-2050-001 |
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Issued By: |
[Your Name] |
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Date: |
September 15, 2050 |
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Email Address: |
[Your Email] |
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Location of Confined Space: |
Main Storage Tank Room, Building A |
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Purpose of Entry: |
|
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Supervisor: |
John Smith |
Entrants (List all personnel entering confined space):
|
Name |
Job Title |
Training |
Rescue Training |
Date of Birth |
Contact Number |
|
Sarah Johnson |
Maintenance Worker |
Yes |
Yes |
07/12/ 2030 |
222 555 7777 |
Attendants (List all personnel stationed outside confined space):
|
Name |
Job Title |
Training |
Rescue Training |
Date of Birth |
Contact Number |
|
Jenny Rodgers |
Safety Officer |
Yes |
Yes |
06/08/ 2010 |
222 555 7777 |
Emergency Contact Information:
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Emergency Services: [911]
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Nearest Hospital: [Unity Hospital]
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Hospital Phone: [222 555 7777]
Hazard Assessment:
Describe all potential hazards within the confined space, including but not limited to:
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Safety Precautions:
List all safety measures and precautions that must be taken before, during, and after entry, including:
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Equipment (List all equipment to be used during entry):
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Equipment Description |
Quantity |
Inspection Date |
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Gas Detector |
2 |
09/01/2050 |
Communication Procedures:
Detail the communication protocols between entrants, attendants, and supervisors during the entry:
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Entry and Exit Procedures:
Provide specific instructions for entering and exiting the confined space:
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Duration of Entry:
Start Time: [8:00 AM]
End Time: [12:00 PM]
Signature and Authorization:
I, [Your Name], authorize and confirm that all personnel involved in this confined space entry have been adequately trained and briefed on the safety procedures outlined in this permit.
Signature: [Signature]
Date: [09/15/2050]
Permit Expiry:
This permit is valid until [09/15/2050] at [12:00 PM]. Entry into the confined space is prohibited after this time without reevaluation.
Important Notes:
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This permit is to be kept on-site and made available for inspection by authorized personnel.
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In case of any changes or deviations from this permit, it must be immediately reviewed and updated by the supervisor.
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Ensure compliance with all applicable safety regulations and guidelines.
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