Human Resources

Shortcuts

Quick Links

CONFINED SPACE RISK ASSESSMENT & ENTRY PERMIT

Print this Page (pdf version)

(rtf version)

RISK ASSESSMENT:

Job Description:
Work to be done by:
Confined Space No.: _ _ _ _ _ _	Location:
Nature of work to be undertaken:

Hazards/Risks associated with task:
1.	2.
3.	4.
5.	6.
7.	8.
9.	10.

Planned control measures to remove/minimise hazards/risks:
1.	2.
3.	4.
5.	6.
7.	8.
9.	10.

Does the Risk Assessment identify that confined space work is involved?:

YES

If YES the confined space work entry permit MUST be completed

NOTE: EMERGENCY & RESCUE PROCEDURES: Where an accident occurs which requires that an emergency rescue be attempted, the Stand-by & Rescue Person is to immediately contact EMERGENCY SERVICES on 000 or 6207 8400 for assistance.

Officer completing Risk Assessment:	Date:	Time:
Uni ID No:

CONFINED SPACE WORK ENTRY PERMIT:

(1) ISOLATION? Is isolation of confined space required? (tick which is applicable): If yes, does the space need to be isolated from:	YES	NO	Isolation done before entry	Isolation restored after exit	Effects of islation on other locations
1. Water/Gas/Steam/Chemicals?	YES	NO
2. Mechanical/Electrical Drives?	YES	NO
3. Auto/Fire extinguishing systems?	YES	NO
4. Hydraulic/Electric/Gas power?	YES	NO
5. Other (specify)?	YES	NO
6. Tags fixed to isolation point?	YES	NO

(2) VENTILATION ADQUATE? (tick which is applicable):	YES	NO
If NO, what kind of ventilation is proposed?: Appropriate ventialtion provided before entry:

(3) ATMOSPHERIC TEST REQUIRED? (tick which is applicable):
If YES:

YES

Measured depth: (three readings must be taken)	Oxygen:	Hydrogen Sulphide:	Other Toxic gas:	Flammable Gases:	Time taken:
Permitted Levels	19.5%-23.5%	10ppm		<5%LEL
1.
2.
3.

(4) PERSONAL PROTECTIVE EQUIPMENT? The following PPE is to be worn/used (tick which is applicable):

1. Respiratory protection

tickbox SCBA

tickbox Air purifying respirator

tickbox Air line

4. Rescue or access equipment

tickbox Escape set

tickbox Communications (eg. 2-way radios)

tickbox Motion detector

tickbox Lifeline

tickbox Lifting gear

2. Eye protection

tickbox Safety glasses

tickbox Goggles

5. Essential requirements

tickbox Fire extinguisher

tickbox First aid kit

tickbox Torch

3. Routine protection

tickbox Gloves

tickbox Overalls

tickbox Chemical suit

tickbox Ear plugs/muffs

tickbox Hard hat

tickbox Safety boots

6. Other (specify):

(6) HOT WORK REQUIRED? If YES complete the following (tick which is applicable):
1. Is site clear of combustibles to 15 metres?	YES	NO
2. Are applicable fire extinguishers on site?	YES	NO
3. Types of fire extinguishers available:
4. Atmosphere free form gasses?	YES	NO
5. Safe access and exit?	YES	NO
6. HOT WORK is allowed?	YES	NO

(7) STAND BY & RESCUE Name(s) of stand by person(s):
Rescue and emergancy procedures understood (tick which is applicable)	YES	NO

MANAGEMENT APPROVAL TO ENTER (tick which is applicable)

The confined space is safe for entry to do the work described provided all nominated precautions are fully observed

YES

All persons on the job have been briefed

YES

Budget Unit Approval

This work entry permit is valid until:

Date:

Time:

Budget Unit:

Print Name:

Signature:

Date:

Time:

All personnel entering and working in the confined space MUST sign below:
SIGN ON: I have been advised of the safety precautions to be taken while working in the confined space covered by this permit. I have been trained to work in confined spaces and consider this site safe to enter.	SIGN OFF: I have now left this confined space and I am aware that should I re-enter it I am required to SIGN ON again.

SIGN ON ENTRY	PRINT NAME	DATE	TIME	Uni ID No.	SIGN OFF ON EXIT
1.
2.
3.
4.
5.

The following new hazards/conditions were identified during completion of this task:

The following gas concentration were measured during the completion of this task	Oxygen, %:	Hydrogen Sulphide, ppm:	Toxic, ppm:	Explosive, %:	Time taken:
1.

EXIT STATEMENT: Work is now completed (or suspended), all personnel have exited the confined space, signed off above, all equipment removed and the confined space may now be secured and this permit cancelled.

Signed:

Date:

Time:

BUDGET UNIT CANCELLATION OF APPROVAL TO ENTER

Budget Unit:

Print Name:

Signature:

Date:

Time:

This permit is now cancelled. Any re-entry or work concerning this confined space requires the issue of a new Confined Space Work Entry Permit.

For further information contact:
Glyn Whitworth, phone: 6125 3656, e-mail: Glyn.Whitworth@anu.edu.au

Page last updated: 26 August 2009
Please direct all enquiries to: HR Business Solutions
Page authorised by: the Director, Human Resources Division

CRICOS Provider Number 00120C - ABN Number: 522 34063906