Confined Space Entry Permit Template

04 Jun 2020 - Flaaim

This permit establishes that all hazards have been identified and controlled and lists authorized entrants, attendant, and entry supervisor. This permit (or equivalent subcontractor’s permit) must be completed and signed by the confined space entry supervisor before work begins, remain in use at the job site until work is complete, and sent to the confined space program manager once work is complete.

Permit Conditions

Reason for entry: Entry date: Permit expiration (date and time): Confined space entry supervisor: Attendant: Attendant: Entrant: Entrant: See the confined space register for the following information Tracking number: Description: Location: Known and potential hazards: Additional required permits (for example hot work, radiological work permit, penetration permit):

Confined Space Entry Permit Template

Required for this entry (check all that apply)


  1. Non-entry rescue equipment
    • Full body harness
    • Tripod / hoist
    • Lifeline
  2. Area security:
    • Warning signs
    • Barricades
  3. Ladder
  4. Fall protection equipment
  5. Ventilation fan or blower
  6. Fire extinguisher
  7. Self-contained breathing apparatus (SCBA)
  8. Air purifying respirator: specify cartridge type:
  9. Other:

Personal protective equipment and personal monitors

  1. Gloves:
    • Leather
    • Impervious
    • Chemical resistant
    • Other:
  2. Face / eye protection:
    • Face shield
    • Goggles
    • Other:
  3. Footwear
  4. Coveralls
  5. Head protection
  6. Radiation dosimeter(s)
  7. Pocket ion chamber (PIC)
  8. Other:

Pre-entry Checklist

  1. Verify adequate confined space training
  2. Pre-entry briefing on specific hazards and control methods
  3. Notify subcontractors of permit and hazard conditions
  4. Non-entry rescue and procedure in place
  5. Notify affected departments and persons of service interruption
  6. Lines blocked or broken
  7. Drain space

    Control of hazardous energy:

  8. Lockout / tagout (LOTO)
  9. Zero-voltage verification (ZVV)
  10. Other


Confined Space Entry Permit Template

Air Monitoring

Attendant will sample air

Monitoring results

Pre-entry Certification (must be signed by the confined space entry supervisor before work begins) I herby certify that all required hazard controls are in place, that air monitoring is being conducted as required and results show that the atmosphere is acceptable for entry, and that all required information is documented on this permit. Signature: Date: Permit Closure (must be signed by the confined space entry supervisor after work is completed) The work was done in accordance with this permit. A copy of this permit will be forwarded to the confined space program manager (Mailstop 84). Signature: Date:

Confined Space Entry Permit Template


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