The document is a confined space entry permit form outlining required details for safe entry and work procedures. It includes sections for project information, permit issuance details, prerequisites, trained personnel, atmospheric conditions, and acknowledgment by involved parties. The form is designed to ensure all safety checks are performed and documented before allowing entry into confined spaces.

1. CONFINED SPACE ENTRY PERMIT
Page 1 of 2 Form # HSEQ-CSE (Rev 3 – Mar 23)
1. Project Information: (To be filled by initiator/originator)
Project Name: Permit No.:
Project Location:
Requesting Contractor/Company
2. Permit Issuance Details: (To be filled by initiator/originator)
(This permit is only for one shift and is not extendable)
Description of Task:
Detail of Surroundings:
Permit Validity: Time (from): __________Hrs. Time (To): __________Hrs. Date:
3. Prerequisites: (To be filled by initiator/originator and verified by Evaluator)
Checks Yes-No-NA Checks Yes-No-NA
Method statement and Risk assessment
developed, approved and communicated?
☐ ☐ ☐ Provision of vigilance supervision? ☐ ☐ ☐
Operatives are trained and competent? ☐ ☐ ☐ Safe means of access/egress provided? ☐ ☐ ☐
Emergency response procedure and rescue plan
are developed & communicated?
☐ ☐ ☐ Means of communication available? ☐ ☐ ☐
Proper signage are posted? ☐ ☐ ☐ Workplace appropriately illuminated? ☐ ☐ ☐
Electrical equipment & connections safe? ☐ ☐ ☐
Ventilation means are available & used
before entry?
☐ ☐ ☐
Gases/ hazardous material Isolation is done
(LOTO)?
☐ ☐ ☐
Will ventilation be continued during
work? (LEV)
☐ ☐ ☐
Mechanical & electrical equipment isolation done
(LOTO)?
☐ ☐ ☐
Harness/lifeline/ mechanical retrieval
system (tripod) available?
☐ ☐ ☐
Will any other equipment be used/ running in the
space?
☐ ☐ ☐ SCBA is maintained & available? ☐ ☐ ☐
Will any chemical be used in the space? ☐ ☐ ☐ Trained stand-by man available? ☐ ☐ ☐
Was the space been found unacceptable? ☐ ☐ ☐ Others( Specify) ☐ ☐ ☐
Mandatory/specific good condition PPEs are
available
☐ ☐ ☐ ☐ ☐ ☐
4. Trained Authorized Individuals: (To be filled by initiator/originator)
Entry Supervisor:
Stand-by Man:
First Aider(s)
Rescuer: 1. 2.
Authorized Entrants: 1. 2.
3. 4.

2. CONFINED SPACE ENTRY PERMIT
Page 2 of 2 Form # HSEQ-CSE (Rev 3 – Mar 23)
Equipment/ Materials
details to be used
Details of Chemicals to
be used (MSDS attached)
5. Atmospheric Conditions: (To be tested by authorized tester)
Authorized Tester(s):
Time O2 LEL H2S CO Heat (C) Other
Pre-entry 1. O2 – 19.5% to 23.5%
2. LEL – less than 10%
3. H2S – below 10 ppm
4. CO – PEL-below 35 ppm
Pre-entry
after Vent
During
Work
Others
Others
6. Acknowledgement by Initiator and Evaluator:
☐ Acknowledge that all above precautions have been taken. These have also been fully explained to the operatives, and I
consider them competent to do it safely.
Initiator/Originator
Name:
Designation:
Signature: Time:
☐ Acknowledge that I have checked above control measures and consider the work area safe to carry out the activity
Evaluator (HSE Team): Designation:
Signature: Time
Comments (if any) :
7. Authorization (PM/CM):
Name: Designation:
Signature: Time:
8. Completion/Cancelation of Permit:
☐ Acknowledge that the area have been restored to a safe and orderly condition.
Initiator Signature: Time:
☐ Acknowledge that I have checked the area and been restored to a safe and orderly condition.
Evaluator Signature: Time: