WineSHIP - Sample Confined Space Entry Permit
Use this medical questionnaire to assess confined space.
MaintainX
10/06/2022
WineSHIP - Sample Confined Space Entry Permit
Use this medical questionnaire to assess confined space.
Date
Site location or description
Purpose of entry
Supervisor(s) in charge of crew
Phone #
Type of crew (welding, plumbing, etc)
Permit duration
Communication procedures (including equipment
Rescue procedures (also see emergency contact phone numbers at end of form)
REQUIREMENTS COMPLETED
Lockout/De-energize/Try-out
Line(s) Broken-Capped-Blank
Purge-Flush and Vent
Ventilation
Secure Area (Post and Flag)
Lighting (Explosive Proof
Hotwork Permit
Fire Extinguishers
Supplied Air Respirator (N/A if alternate entry)
Respirator(s) (Air Purifying)
Protective Clothing
Full Body Harness w/"D" ring
Emergency Escape Retrieval Equipment
Lifelines
Standby safety personnel (N/A if alternate entry)
Resuscitator-Inhalator (N/A if alternate entry)
Add other specific information, if needed, or attach additional instructions or requirements. See the following examples in bold print.
Line(s) to be bled/blanked
Ventilation equipment
PPE clothing
Respirator(s)
Fire extinguisher(s)
Emergency retrieval equipment
AIR MONITORING
Substance Monitoring
LEL/LFL
Toxic 1
Toxic 2
Toxic 3
Toxic 4
Permissible Levels
Under 10%
PEL & STEL 1
PEL & STEL 2
PEL & STEL 3
PEL & STEL 4
Monitoring Results
REMARKS
Air Tester Name
ID#
Instrument(s) Used (For example: oxygen meter, combustible gas indicator, etc.)
Model# or Type
Serial# or Unit
ATTENDANTS AND ENTRANTS
Attendant(s) (Required for all confined space work except alternate entry)
ID#
Confined Space Entrant(s)
ID#
REMARKS:
SUPERVISOR AUTHORIZATION - ALL CONDITIONS SATISFIED
Department or phone number:
EMERGENCY CONTACT PHONE NUMBERS:
AMBULANCE
FIRE
SAFETY
RESCUE TEAM
OTHER
Source: MaintainX (Community Member)