QPERM-Confined Space Entry Permit

Guides:

Permit to Work Guide

Sample Permits to Work:

Control Document

General Permit to Work

Complies with NFPA 51B - Standard for Fire Prevention During Welding, Cutting and Other Hot Work

CONFINED SPACE

Issuing Permits - The issue of permits is strictly controlled, permits can only be issued by authorised personnel.

PERMIT NUMBER:

CONTRACTOR (Company):

CONTRACTOR (Employee Name):

LOCATION OF WORK (Exact):

DESCRIPTION OF WORK:

SPECIAL INSTRUCTIONS:

Withdrawal From Service:

The above plant has been removed from service and persons under my supervision have been informed.

Signed:

Date:

Permit Controller:

Time:

Isolation:

The above plant has been isolated from all sources of ingress of dangerous fumes and other atmospheres.

Signed:

Date:

Permit Controller:

Time:

Cleaning and Purging:

The above plant has been freed of all dangerous materials:

Materials:

Methods:

Signed:

Date:

Permit Controller:

Time:

Testing

The above plant has been testing to ensure that it is safe to enter:

Contaminants Tested:

Methods:

Signed:

Date:

Permit Controller:

Time:

Authorisation to Proceed

I certify that I have personally examined the above plant and satisfied myself that the above particulars are correct and that:

The plant is safe for entry without breathing apparatus.
Approved breathing apparatus must be worn.

Delete (1) or (2) as appropriate.

Other Precautions:

Signed:

Date:

Permit Controller:

Time:

Acceptance by competent person prior to commencement

I understand the work that is to be carried out and the safety precautions that are necessary to complete the work safely as outlined in the appropriate method statement and risk assessments. If conditions are such that the method statement and risk assessments become invalid it is my responsibility to stop work immediately and notify the person who authorised this permit to work.

Signed:

Date:

Competent Person:

Time:

Continuation of Work

I hereby authorise the work specified above to continue until the time stated below and that I have checked the safety arrangements and confirm that they remain adequate.

Permit has been extended to:

am / pm

Signed:

Date:

Permit Controller:

Time:

Permit Cancellation

This permit is cancelled. The work is / is not complete. Safety precautions have / have not been removed.

Signed:

Date:

Permit Controller:

Time:

Completion of Work
Final check by Contractor / Employee

I declare that the work described above is complete all work equipment, persons and materials under my control have been withdrawn. All safeguards have been reinstated and the work area returned to a safe status and service.

Signed:

Date:

Competent Person:

Time:

Completion of Permit - Permit Controller

I declare that the permit is now closed and I have received copies of the permit back from the Competent Person. The area has been inspected and is free from risk and all fire protection systems have been reinstated to their normal operating status.

Signed:

Date:

Permit Controller:

Time: