Confined Space Permit
This procedure outlines the requirements for issuing, monitoring, and closing a confined space permit before work begins. It helps ensure hazards, controls, personnel, and emergency preparations are properly documented so the job can be carried out safely and in compliance with permit requirements.
Manaaki Whenua Landcare ResearchI
03/23/2026
Confined Space Permit
This permit must be accompanied with a Gas Testing Register, Task Analysis and Entry Log
Permit to Work
Work Details
Enter Work Scope
Enter Work Location
Select other types of permits required to complete this task
Notifiable Works
Is the work WorkSafe Notifiable?
if the answer is "oneOf [Yes]"
Enter the name of the person who notified WorkSafe
if the answer is "oneOf [Yes]"
Date WorkSafe notified
Attach evidence of notification if available
Add or drag pictures
Personnel Details
Enter Permit Receiver details
Person and Company Name and contact number
Enter Permit Issuer details
Name and contact number
Enter Safety Observer details
Tools and Equipment
List required tools and equipment
Do any tools/equipment require certification?
if the answer is "oneOf [Yes]"
Are all certifications in date?
if the answer is "oneOf [No]"
Do not start work until item is either certified or replacement certified item is sourced
Toolbox Talk
Enter names and roles of attendees
Toolbox Talk Confirmation Signatures
By signing this document you confirm your attendance at the toolbox talk and that you understand and will accept the Permit requirements
Click here to sign
Permit Authorisation
All isolations have been tested and verified?
Stakeholders have been notified?
This Permit is valid from
To
Permit Receiver Signature
Click here to sign
Permit Issuer Signature
Click here to sign
Confined Space Checklist
Workers have current Confined Space training and a First Aider is present
if the answer is "oneOf [No]"
All safety/rescue equipment is checked and certified
Have barriers been erected?
if the answer is "oneOf [Yes]"
Are warning signs required?
if the answer is "oneOf [Yes]"
Will the task include the use of hazardous substances?
if the answer is "oneOf [Yes]"
Have isolations (LOTO) been applied, tested, and verified?
Will the task introduce electrical hazards?
Will the task create elevated noise levels?
if the answer is "oneOf [Yes]"
Will the task change the atmosphere?
if the answer is "oneOf [Yes]"
Detail how space will be ventilated
List other checks
Safety Observer Pre-Entry Declaration
By signing below, I confirm that I understand the permit requirements, that I have been advised and briefed on work tasks, hazards, precautions, and the emergency plan, and that I agree to abide by these conditions.
Safety Observer Name
Safety Observer Signature
Click here to sign
Safety Observer Comments
Safety Observer Exit Declaration
By signing below, I confirm that all persons entering the confined space have been accounted for and that post-exit gas test results have been checked and recorded.
Safety Observer Name
Safety Observer Signature
Click here to sign
Safety Observer Comments
Permit Audit & Completion
Audit
Contractor's Health & Safety measures in line with Permit conditions
Permit Closure
Only to be completed when the permit is closed or cancelled
This permit is being
if the answer is "oneOf [Cancelled]"
Enter reason for cancellation
All isolations have been removed
Tools etc have been removed/accounted for
The worksite has been left in a clean and safe condition
Stakeholders have been notified
if the answer is "oneOf [Yes]"
Permit Receiver Signature
Click here to sign
Permit Issuer Signature
Click here to sign
Source: Manaaki Whenua Landcare ResearchI (Community Member)