Step 1 of 8 12% TRAINING COURSESelect your course* Confined Space Training Work Safely at Heights STEP 1: SAFE WORK METHOD STATEMENT (SMWS)Complete this step individually or in a group, as instructed by your trainer.Workplace location* Task* Date* DD slash MM slash YYYY Note: Moderate risk (4) requires constant vigilance. Increased levels of risk (3-2-1) require task redesign or written CEO approval to proceed.FIRST STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No SECOND STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No THIRD STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No FOURTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No FIFTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No SIXTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No SEVENTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No EIGHTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No NINTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeAdd another step?* Yes No TENTH STEPStep in task*Select...Set up sitePrepare to enter the confined spaceEnter & work in the confined spaceExit the confined spacePack up the siteStep in task*Select...Set up siteClimb ladderTransfer to / from platformInstall or dismantle static linePack up the siteHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsUnsafe atmosphereHazard*Select...Interaction with othersFaulty equipmentUnisolated energyManual handlingFall from heights or falling objectsSlips, trips, fallsRisk ranking*Select...LowModerateHighExtremeControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionVentilate & test atmosphereIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionControls*Select...Place signs & barricadesPositive communicationsPre-use inspectionIsolate energy sourcesCorrect manual handling techniquesWear harness, use fall prevention equipment & remain attached at all times keeping connections as high as possibleGood housekeeping, lighting & edge protectionRisk ranking*Select...LowModerateHighExtremeADDITIONAL STEP (OPTIONAL)Step in taskHazardRisk rankingSelect...LowModerateHighExtremeControlRisk rankingSelect...LowModerateHighExtremeNumber of people completing this SWMS*12345678910111213141516Name* First Last Signature*Name of 1st person completing this SWMS* First Last Signature of 1st person completing this SWMS*Name of 2nd person completing this SWMS* First Last Signature of 2nd person completing this SWMS*Name of 3rd person completing this SWMS* First Last Signature of 3rd person completing this SWMS*Name of 4th person completing this SWMS* First Last Signature of 4th person completing this SWMS*Name of 5th person completing this SWMS* First Last Signature of 5th person completing this SWMS*Name of 6th person completing this SWMS* First Last Signature of 6th person completing this SWMS*Name of 7th person completing this SWMS* First Last Signature of 7th person completing this SWMS*Name of 8th person completing this SWMS* First Last Signature of 8th person completing this SWMS*Name of 9th person completing this SWMS* First Last Signature of 9th person completing this SWMS*Name of 10th person completing this SWMS* First Last Signature of 10th person completing this SWMS*Name of 11th person completing this SWMS* First Last Signature of 11th person completing this SWMS*Name of 12th person completing this SWMS* First Last Signature of 12th person completing this SWMS*Name of 13th person completing this SWMS* First Last Signature of 13th person completing this SWMS*Name of 14th person completing this SWMS* First Last Signature of 14th person completing this SWMS*Name of 15th person completing this SWMS* First Last Signature of 15th person completing this SWMS*Name of 16th person completing this SWMS* First Last Signature of 16th person completing this SWMS* STEP 2: PERMIT CONTROLSComplete this step individually or in a group, as instructed by your trainer.IsolationsSelect 'Yes' for those that apply and 'No' for those that don't. For those that apply, you need to provide details and identify the isolation point.Water / gas / steam / chemicals* Yes No DetailsIf applicableIsolation pointIf applicableMechanical / electrical drives* Yes No DetailsIf applicableIsolation pointIf applicableHydraulic / electric / gas / power* Yes No DetailsIf applicableIsolation pointIf applicableSludge / deposits / waste* Yes No DetailsIf applicableIsolation pointIf applicableAuto fire extinguishing system* Yes No DetailsIf applicableIsolation pointIf applicablePersonal Protective Equipment (PPE)Applicable PPE* Respiratory protection Harness / lifeline Eye protection Hand protection Footwear Hearing protection Head protection Communication equipment Protective clothing Atmospheric ControlsSelect 'Yes' for those that apply and 'No' for those that don't. For those that apply, you need to provide details.Depressurise* Yes No DetailsIf applicableNatural ventilation* Yes No DetailsIf applicablePurging or extraction* Yes No DetailsIf applicablePre-entry atmospheric monitoring* Yes No DetailsIf applicableContinuous atmospheric monitoring* Yes No DetailsIf applicableHourly atmospheric monitoring* Yes No DetailsIf applicableAtmospheric monitoring at nominated frequency* Yes No DetailsIf applicableAtmospheric MonitoringSelect applicable atmospheric monitoring* Oxygen (O2) Carbon monoxide (CO) Hydrogen sulphide (H2S) Lower Explosive Limit (LEL) Ammonia (NH3) Carbon dioxide (CO2) Other If other, please specify* Other ControlsSelect 'Yes' for those that apply and 'No' for those that don't. For those that apply, you need to provide details.Warning signs in place* Yes No DetailsIf applicableBarricading in place* Yes No DetailsIf applicableAll workers trained & competent* Yes No All workers trained & competent*Including safety observer Yes No DetailsIf applicableSuitable lighting* Yes No DetailsIf applicableWorking in accordance with other permits* Yes No DetailsIf applicable STEP 3: EMERGENCY PLANRescue TypeSelect applicable rescue types* Engulfment Toxic atmosphere Explosive atmosphere Fall from heights Medical emergency Fire Rescue TypeSelect applicable rescue types and provide detailsFall from heights* Yes No DetailsSuspended in harness* Yes No DetailsMedical emergency* Yes No DetailsFire* Yes No DetailsCommunication & Emergency PreparationEmergency phone number*Emergency radio channelStandby person (name)* Safety observer (name)* Evacuation assembly point* Emergency services meeting point* Incident controller (name)* Emergency EquipmentSelect applicable emergency equipment* Safety harness Tripod Davit arm Attachment point Roll up stretcher / slide First Aid kit Gas monitor Ventilation equipment Breathing apparatus Basket stretcher Defibrillator Select applicable emergency equipment* Safety harness Tripod Davit arm Attachment point Roll up stretcher / slide Ladder Elevated Work Platform Basket stretcher First Aid kit Defibrillator Rescue PlanStep 1 details*Responsible person*Add another step?* Yes No Step 2 details*Responsible person*Add another step?* Yes No Step 3 details*Responsible person*Add another step?* Yes No Step 4 details*Responsible person*Add another step?* Yes No Step 5 details*Responsible person*Add another step?* Yes No Step 6 details*Responsible person*Add another step?* Yes No Step 7 details*Responsible person*Add another step?* Yes No Step 8 details*Responsible person*Add another step?* Yes No Step 9 details*Responsible person*Add another step?* Yes No Step 10 details*Responsible person* Answer the following 3 questions with reference to your rescue plan and the image above.At what position is the casualty?* A B C D E F G At what position is the rescuer?* A B C D E F G At what position is the standby / safety observer?* A B C D E F G STEP 4: PRE-WORK TESTINGAtmospheric MonitoringOxygen (O2) reading (%)Safe range: 19.5%-23.5%Safe to enter* Yes No N/A Carbon monoxide (CO) reading (ppm)Safe range: less than 30 ppmSafe to enter* Yes No N/A Hydrogen sulphide (H2S) reading (ppm)Safe range: less than 10 ppmSafe to enter* Yes No N/A Lower Explosive Limit (LEL) reading (%)Safe range: less than 5%Safe to enter* Yes No N/A Other reading Safe to enter Yes No The atmosphere is safe to enter with / without respiratory protection* With Without Entry PermitConditions of entryPermit is valid until (time)* Permit is valid until (date)* DD slash MM slash YYYY Testing PersonName* First Last Signature*Time* Date* DD slash MM slash YYYY STEP 4: PRE-WORK TESTING / INSPECTIONTestingEquipment pre-start inspection detail Reading / authorisation Safe to work* Yes No N/A Wind speedSafe range: less than 12 m/sSafe to work* Yes No N/A Ground assessment detail Reading / authorisation Safe to work* Yes No N/A Services location detail Reading / authorisation Safe to work* Yes No N/A Other Reading / authorisation Safe to work* Yes No N/A PermitConditions of entryPermit is valid until (time)* Permit is valid until (date)* DD slash MM slash YYYY Testing / Inspecting PersonName* First Last Signature*Time* Date* DD slash MM slash YYYY STEP 5: PERMIT AUTHORISATION1. Permit application*I am applying for approval of this permit under the conditions specified in this document First Name Last Name Signature*Time* Date* DD slash MM slash YYYY 2. Pre-work testing*I have completed atmospheric testing and declare the confined space safe to enter First Name Last Name 2. Pre-work testing*I have completed testing and inspection and declare the work safe to commence First Name Last Name Signature*Time* Date* DD slash MM slash YYYY 3. Validation & Authorisation*I have inspected the worksite and found the conditions to comply with those of the permit, and I give approval for the work of this permit to proceed First Name Last Name Signature*Time* Date* DD slash MM slash YYYY 4. Permit holder*I accept this authorised permit and have ensured that all controls are in place ready for the work to proceed First Name Last Name Signature*Time* Date* DD slash MM slash YYYY Next StepProceed to practical (Step 6) or close permit (Step 7)?*Choose the option as instructed by your trainer. Step 6: Carrying Out & Monitoring Work Step 7: Closing Permit STEP 6: CARRYING OUT & MONITORING WORKAtmospheric MonitoringFIRST RECORDINGDate* DD slash MM slash YYYY Time* Oxygen (O2) reading (%)*Carbon monoxide (CO) reading (ppm)*Hydrogen sulphide (H2S) reading (ppm)*Lower Explosive Limit (LEL) reading (%)*Safe to enter* Yes No Signature*Add another recording?* Yes No SECOND RECORDINGDate* DD slash MM slash YYYY Time* Oxygen (O2) reading (%)*Carbon monoxide (CO) reading (ppm)*Hydrogen sulphide (H2S) reading (ppm)*Lower Explosive Limit (LEL) reading (%)*Safe to enter* Yes No Signature*Add another recording?* Yes No THIRD RECORDINGDate* DD slash MM slash YYYY Time* Oxygen (O2) reading (%)*Carbon monoxide (CO) reading (ppm)*Hydrogen sulphide (H2S) reading (ppm)*Lower Explosive Limit (LEL) reading (%)*Safe to enter* Yes No Signature*Add another recording?* Yes No FOURTH RECORDINGDate* DD slash MM slash YYYY Time* Oxygen (O2) reading (%)*Carbon monoxide (CO) reading (ppm)*Hydrogen sulphide (H2S) reading (ppm)*Lower Explosive Limit (LEL) reading (%)*Safe to enter* Yes No Signature*Entry & Exit RegisterFIRST ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*FIRST EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No SECOND ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*SECOND EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No THIRD ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*THIRD EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No FOURTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*FOURTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No FIFTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*FIFTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No SIXTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*SIXTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No SEVENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*SEVENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No EIGHTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*EIGHTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No NINTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*NINTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No ELEVENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*ELEVENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWELFTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWELFTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No THIRTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*THIRTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No FOURTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*FOURTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No FIFTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*FIFTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No SIXTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*SIXTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No SEVENTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*SEVENTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No EIGHTEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*EIGHTEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No NINETEENTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*NINETEENTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWENTIETH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWENTIETH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWENTY FIRST ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWENTY FIRST EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWENTY SECOND ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWENTY SECOND EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWENTY THIRD ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWENTY THIRD EXITExit date* DD slash MM slash YYYY Exit time* Signature*Add another entry & exit?* Yes No TWENTY FOURTH ENTRYEntry date* DD slash MM slash YYYY Entry time* Name* First Last Signature*TWENTY FOURTH EXITExit date* DD slash MM slash YYYY Exit time* Signature*Suspension of WorkAny suspension(s)? Yes No FIRST SUSPENSIONDate* DD slash MM slash YYYY Time* Reason*Standby person's name* First Last Safety observer's name* First Last Signature*Add another suspension?* Yes No SECOND SUSPENSIONDate* DD slash MM slash YYYY Time* Reason*Standby person's name* First Last Safety observer's name* First Last Signature*Add another suspension?* Yes No THIRD SUSPENSIONDate* DD slash MM slash YYYY Time* Reason*Standby person's name* First Last Safety observer's name* First Last Signature*Recommencement of WorkThe reason for suspending work has been addressed and the Safe Work Method Statement updated. The Permit Issuer has conducted an inspection prior to revalidating the permit.FIRST RECOMMENCEMENTDate* DD slash MM slash YYYY Time* Details of hazard controls implemented for revalidation*Permit issuer's name* First Last Signature*SECOND RECOMMENCEMENTDate* DD slash MM slash YYYY Time* Details of hazard controls implemented for revalidation*Permit issuer's name* First Last Signature*THIRD RECOMMENCEMENTDate* DD slash MM slash YYYY Time* Details of hazard controls implemented for revalidation*Permit issuer's name* First Last Signature*Standby / Safety Person HandoverAny handover(s)?* Yes No FIRST HANDOVERDate* DD slash MM slash YYYY Time* From* First Name Last Name Signature*To* First Name Last Name Signature*Add another handover?* Yes No SECOND HANDOVERDate* DD slash MM slash YYYY Time* From* First Name Last Name Signature*To* First Name Last Name Signature*Add another handover?* Yes No THIRD HANDOVERDate* DD slash MM slash YYYY Time* From* First Name Last Name Signature*To* First Name Last Name Signature* STEP 7: CLOSING PERMITAll work under this permit has concluded. An inspection has been carried out and all personnel and equipment has been removed from the confined space. The space has been secured, all isolations have been removed, and the confined space is ready to return to normal operation.All work under this permit has concluded. An inspection has been carried out and all personnel are accounted for and equipment has been inspected & returned to the nominated storage locations. Any isolations have been removed, and the area is ready to return to normal operation.* This permit is now closed. Date* DD slash MM slash YYYY Time* Name* First Last Signature*The submitted permit will be forwarded to the Permit Office. Press 'Submit' to complete this form.
