Attachment 2 - Chapter 1.9 Confined Space Entry Attachment A.docx
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Attachment A
| VA Medical Center | Safety Manual |
| Atlanta, GA | Chapter 1, Section 9 |
CONFINED SPACE ENTRY PERMIT
(Pre-entry Checklist)
Section I: (All attendants and entrants shall review the confined space entry permit and sign the confined space entry log prior to entry!)
| Type of Space: ____________________ | Space Location: ____________________________ | |
| Date/Time Issued: __________________ | Permit Expiration: (Date/Time) _______________ |
Safety Office Staff: ______________________ Description of work to be performed: _________________________________________________
| NATURE OF HAZARDS IN SPACE: | PERSONAL PROTECTIVE EQUIPMENT: | |||
| (N/A, YES, or NO) | (N/A, YES, or NO) | |||
| ____ Oxygen Deficiency/Excess | ____ Hard Hat | ____ Clothing | ||
| ____ Flammable Material | ____ Safety Glasses | ____ Footwear | ||
| ____ Corrosive Material | ____ Goggles | ____ Communication | ||
| ____ Toxic Material | ____ Face Shield | ____ Other: ________ | ||
| ____ Mechanical Hazards | ____ Gloves | ____ Other: ________ | ||
| ____ Electrical Shock | ____ Respirator/Type: _____ | |||
| ____ Materials Harmful to the Skin | ____ Hearing Protection | |||
| ____ Engulfment | ____ Safety Harness/Life-line |
____ Heat-Stress Environment
| ____ Pressure System Environment | AUTHORIZED ENTRANT (S): | ||||
| ____ Other: ________________ | _____________________ _____________________ | ||||
| ____ Other: ________________ | _____________________ _____________________ | _____________________ _____________________ PREPARATION & ISOLATION: | _____________________ _____________________ | (N/A, YES, or NO) | |
| ____ Notify Affected Service Lines of Entry | AUTHORIZED ATTENDANT (S): | ||||
| ____ Locked and Tagged - Electrical | _____________________ _____________________ | ||||
| ____ Locked and Tagged - Mechanical | _____________________ _____________________ | ||||
| ____ Cleaned, Drained, Washed & Purged | _____________________ _____________________ |
____ Ventilated to Provide Fresh Air
| ____ Emergency Response Team Available | OTHER PERMITS REQUIRED: | ||
| ____ Employees Informed of Specific | ____ Respirator | ____ Hot-Work | |
| Confined Space Hazards | ____ Other: ______________________ |
____ Procedures Reviewed with each Employee
| ____ Atmospheric Test for Compliance: | _____________________________________________ | |
| ____ Low-Voltage/Explosion-Proof Lighting | Job Supervisor (Signature) (Date) | |
| ____ Ground Fault Circuit Interrupters | Time: ______, Oxygen: ____%, | |
| ____ Other: _________________________ | Explosive: ____%L.F.L., Toxic: ______PPM |
SECTION II: Safety Office Staff Final Review (Comments): ________________________________ _______________________________________________ DATE: ______________________________
1.9-A1, February 2025 1.9-C1, April 2001
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