📍 When to use this template
- Before any person enters a confined space (e.g., STP/WTP tank, manhole, vessel, deep trench > 1.2m, large diameter pipe).
- A new permit is required for each shift or each new entry after a break. It has a limited validity, typically 8 hours.
- Filled by the executing agency's Site Supervisor, checked by the Safety Officer, and approved by the Site-in-Charge/Area Owner before entry.
Sections & fields
Preview of the template structure. Download Excel to fill on site.
1Header / Project Information7 fields
Project Name
_____________
Contract / Package No.
_____________
Date & Time of Issue
_____________
Location of Confined Space (Grid/Chainage/Building)
_____________
Permit Valid From (Date & Time)
_____________
Permit Valid To (Date & Time)
_____________
2Work Description & Personnel5 fields
Brief Description of Work to be Done
_____________
Name of Entrant(s) (Worker inside)
_____________
Name of Attendant / Standby Person (Worker outside)
_____________
Name of Entry Supervisor
_____________
Tools & Equipment to be Used (Specify if electrical/sparking)
_____________
3Pre-Entry Hazard Checks (Tick Yes/No/NA)7 fields
Isolation Confirmed (Electrical, Mechanical, Process - LOTO Applied)
_____________
Purging / Ventilation Done & Maintained?
_____________
Access & Egress Clear?
_____________
Barricading & Warning Signage in Place?
_____________
Adequate Lighting Provided (24V only)?
_____________
Communication Method Established (Entrant-Attendant)?
_____________
Previous Contents of Space Identified & Neutralized?
_____________
4Atmospheric Testing Results (Mandatory)8 fields
Testing Instrument ID & Calibration Date
_____________
Oxygen (O2) % (Acceptable: 19.5% - 23.5%)
_____________
Flammable Gas (% LEL) (Acceptable: <10%)
_____________
Toxic Gas (H2S ppm) (Acceptable: <10 ppm)
_____________
Toxic Gas (CO ppm) (Acceptable: <25 ppm)
_____________
Other Gases (Specify)
_____________
Tested By (Name & Signature)
_____________
5PPE & Rescue Equipment6 fields
Full Body Harness & Lifeline for each Entrant
_____________
Helmet, Safety Shoes, Gloves
_____________
Respiratory Protection (SCBA/Airline Respirator as required)
_____________
Emergency Rescue Team Identified & Briefed?
_____________
Rescue Equipment Available & Checked (Tripod, Winch, Stretcher)
_____________
First Aid Kit & Ambulance Availability Confirmed
_____________
6Authorization & Acceptance4 fields
Permit Issuer (Executing Agency Supervisor)
_____________
Permit Receiver (Work Supervisor)
_____________
Checked By (Safety Officer)
_____________
Approved By (Site-in-Charge / Area Owner)
_____________
7Permit Closure7 fields
Work Completed?
_____________
All Personnel Accounted For & Out?
_____________
Tools & Equipment Removed?
_____________
Area Cleaned & Restored?
_____________
LOTO Removed?
_____________
Closure Time & Date
_____________
Closed By (Supervisor Signature)
_____________
💡 Sample filled excerpt
Location: STP Tank No. 2, Basement-1. Work: Internal waterproofing touch-up. Atmospheric Test: O2: 20.9%, LEL: 0%, H2S: 0 ppm, CO: 2 ppm. Entrant: Ram Singh. Attendant: Suresh Kumar. Rescue: Tripod with winch and SCBA set ready at manhole.
⚖ Compliance notes
- Fulfills requirements under The Building and Other Construction Workers (BOCW) Central Rules, 1998, specifically Rule 36(k) and Rule 223.
- Helps demonstrate due diligence as per Section 37 of the BOCW Act, 1996, regarding general safety precautions.
- Essential documentation for internal safety audits, client EHS inspections, and statutory inspections by the Labour Department or DISH.
- Aligns with best practices outlined in IS 15048:2001 (Code of practice for work in confined spaces).