CONFINED SPACE PRE-ENTRY CHECKLIST
LOCATION DATE TIME
ENTRY SUPERVISOR PHONE
Mark the appropriate column: X Yes, X No, or X N/A Not Applicable. Yes No N/A
1. Is a “DANGER CONFINED SPACE” sign posted to identify the site as requiring a
confined space entry permit to occupy the area?
2. Is a written permit space entry program developed and implemented that complies
with Section 1910.146(c)(4)?
3. Is the written program available for inspection by employees and their representa-
tives?
4. Have all ENTRANTS been provided training and acquired the understanding,
knowledge and skills necessary for the safe performance of the duties assigned in
Section 1910.146(h)?
5. Have all ATTENDANTS been provided training and acquired the understanding,
knowledge and skills necessary for the safe performance of the duties assigned in
Section 1910.146(i)?
6. Have all ENTRY SUPERVISORS been provided training and acquired the under-
standing, knowledge and skills necessary for the safe performance of the duties
assigned in Section 1910.146(j)?
7. Is the only hazard an actual or potential hazardous atmosphere?
8. Will continuous forced air ventilation alone be sufficient to maintain the permit space
safe for entry?
9. Has monitoring and inspection data been developed to eliminate the hazardous
atmosphere through forced air ventilation?
10. Has the permit space been isolated?
11. Have steps been taken for purging, inerting, flushing or ventilating the permit space
to eliminate or control atmospheric hazards?
12. Is monitoring available to verify that conditions are acceptable for entry throughout
the duration of an authorized entry?
13. Are employees trained on how to maintain and properly use testing and monitoring
equipment?
© Copyright J.J. Keller & Associates, Inc Neenah, WI USA (800) 327-6868
Page 2
Mark the appropriate column: X Yes, X No, or X N/A Not Applicable. Yes No N/A
14. Is ventilating equipment needed to obtain acceptable entry?
15. Is communication equipment necessary and available for use between attendant and
entrant?
16. Are the entrants provided with personal protective equipment to be adequately pro-
tected insofar as feasible engineering and work practice controls allow?
17. Has adequate lighting equipment been supplied to allow a safe work area and allow
a quick exit in an emergency?
18. Has the area been secured with barriers and shields from pedestrian, vehicle or
other barriers to protect the entrants from external hazards?
19. Is the confined space provided with equipment, such as ladders, needed for safe
ingress and egress by authorized entrants?
20. Is there other training, equipment or services needed to provide safe confined space
entry?
SAFETY EQUIPMENT CHECKLIST
Safety Harness Ear Protection
with Attached Life Lines
Foot Protection
Respirator and type
Protective Clothing
Ventilator
Hard Hat
Resuscitator
Eye Protection
Communications Equipment
Hand Protection
Gas Tester with Alarms
Other (specify)
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GAS TESTS TAKEN
PERMISSIBLE INSTRUMENT ACTUAL TESTED
GAS ENTRY LEVEL YES NO USED READING BY
1. Oxygen % 19.5% to 23.5%
2.
3.
4.
5.
6.
7.
8.
9.
10.
Calibrated direct-reading instruments used to test confined space atmosphere:
1. Name Name
Make Make
Serial No. Serial No.
Last Calibration Date Last Calibration Date
RESCUE AND EMERGENCY SERVICES
1. Contacts in the event of an emergency include name and telephone number.
A. C.
B. D.
2. Rescue services available for this confined space entry.
employee outside rescue service
3. Rescue Equipment available:
Oxygen Chest/full body harness
Resuscitator - Inhalator Retrieval line properly installed
First Aid Equipment Wristlets when it is the safest and
most effective alternative
De-Fibrillator
Additional rescue equipment available
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NOTES
This is an example only of a CONFINED SPACE PRE-ENTRY CHECKLIST. The actual Pre-Entry Checklist
you will use depends on the atmospheric and physical hazards of that particular confined space. All regula-
tions for that permit are addressed in 29 CFR Part 1910 Permit-Required Confined Spaces for General
Industry; Final Rule.
© Copyright J.J. Keller & Associates, Inc Neenah, WI USA (800) 327-6868
