Permit to Work – Confined Space

Company Name:

Date:

NAME OF ORGANISATION: / DATE:
Department/Section: / Issued To:
THIS FORM MUST BE FULLY COMPLETED/DELETED AS APPROPRIATE BEFORE WORK COMMENCES
Part 1. Description Of Work To Be Carried Out - To be completed by the Authorised Person responsible for the work.
1. Precise location of work / 2. Work to be undertaken
Part 2. Isolation Of Equipment (Specify where necessary) - To be completed by the Authorised Person responsible for the work.
Yes / NO
1. Electrical Power
2. Mechanical Power
3. Heat
4. Valves
5. Pipelines
6. Other (Specify) ………………………………………………………………………………………………………………
Part 3. Safety Precautions – To be completed by the Authorized Person responsible for the work.In addition to the isolation procedures listed in Part 2, the following safety precautions have been undertaken
Yes / NO
1. Safety Harness
2. Safety Helmet
3. Bump Cap
4. Ear Protection
5. Eye Protection
6. Gloves
7. Gauntlets
8. Overalls
9. Non-sparking Tools
10. Ventilation (natural)
11. Ventilation (mechanical)
12. Anti-static footwear
13. Lifeline
14. Fire Appliances
15. Roadwork Signs
16. Communication Equip.
17. Lamp (Cap or hand)
18. Monitoring Equip.
19. Barriers
20. Rubber thigh/knee boots
21. Airline BA
22. Self contained BA
23. Two Standby rescuers -
Equipped with:-
24. Breathing Apparatus
25. Lifeline
26. Reviving Apparatus
27. Communication
Part 4. Other Permits required e.g. Hot Work etc.
Permit required / Issued by
Part 5. Atmospheric Testing (Where relevant) – To be completed by the Authorised Person responsible for the work.
Contaminants tested / Results / Safe / Not Safe (Specify)
Part 6. Authorisation And Acceptance Of Permits
AUTHORISATION – To be completed by the Authorised Person responsible for the work.
I have examined the area/equipment specified and permission is given for the work to start subject to the conditions specified.
This work is under the control of : ………………………………………………..……………………..
Signed: ………………………………………….. Position: ……………..…………………………….
Date: …………………………………………….
ACCEPTANCE – To be completed by the person in charge of the work.
I have read, understood and accept the conditions of this Permit.
Signed: ………………………………………... Position: ………………………………………….….
Date: ……………………………………..……
Part 7. Duration Of Permit
Part 1.  This permit is valid from Hrs. to Hrs. on
(Maximum of one shift)
Part 2.  This permit is extended from Hrs. to Hrs. on
Signed: ………………………………………… Position: …………………………………………….
Part 8. Completion Of The Work And Cancellation Of Permit
1.  COMPLETION – To be completed by the person in charge of the work.
All persons under my charge have been withdrawn. The permitted work is / is not complete.
Signed: …………………………………………..
Position: …………………………………………
Time: ……………….. Date: ………………….. / 2.  CANCELLATION – To be completed by the Authorised Person responsible for the work.
This permit is cancelled. I have notified the line manager specified that the work is / is not complete; and the area / equipment is / is not safe to use.
Signed: …………………………………………..
Position: …………………………………………
Time: ……………….. Date: …………………..