Non-Permit Confined Space Entry

Non-Permit Confined Space Entry
Status*

OpenClosedCancelled
State
Project Name*
Project Number
Reason For Cancellation
Date

MonthDayYear
Date
Entry Supervisor*

First NameLast Name
Entry Supervisor Email*
example@example.com
Authorized Entrant(s)
Authorized Attendant(s)
Entry Location
be specific
Reason for Entry
Expected Duration of Entry
Is this a printed/paper permit?

Yes
Upload printed permit or any supplementary documents

Browse Files

Cancelof
Atmospheric Test Results
% of Oxygen (allowable level 19.5% to 23.5%):
% LEL (allowable level 0%):
Carbon Monoxide (allowable level 0%)
Hydrogen Sulfide (allowable level 0%)
Confined Space Evaluation
1. Is the gas monitor current on calibrations

YesNo
2. Are test readings within the "Allowable Level"

YesNo
3. Is there a material that can engulf the entrant

YesNo
4. Could entrant be trapped, crushed or smothered

YesNo
5. Are there any additional uncontrolled safety hazards present

YesNo
6. Can the space be maintained as safe during work

YesNo
7. Are the entrants properly trained

YesNo
8. Are the attendants properly trained

YesNo
9. Are rescue procedures and equipment available

YesNo
10. Are attendants rotated every two hours

YesNo
*STOP*

Based on the above answers you provided, a Confined Space Entry Permit IS required. Please proceed with your plan by first meeting all the requirements of the Confined Space Entry Permit.
Acceptance
Entry Supervisor (ES) Hand Typed Name Acts as Approval
Please print AS Name Here
Should be Empty:

Atmospheric Test Results