ATTACHMENT XI _ CONFINED SPACE ENTRY PERMIT.pdf
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- Solicitation number
- 36C25026Q0789
About this file
This is a Confined Space Entry Permit form used by the VA's Office of Inspector General (VANIHCS) to authorize and document safe entry into confined spaces.
The permit establishes comprehensive safety requirements and monitoring procedures before personnel may enter a confined space. It captures essential administrative information including the permit date, start and end times, issuer identification, jobsite location, entry purpose, supervising crew details, and contact information. The form requires completion of multiple safety prerequisites organized into two columns, including lockout/tagout procedures, ventilation, secured area posting, lighting, hotwork permits, fire extinguishers, supplied air respirators, protective clothing, full body harnesses with D-rings, emergency retrieval equipment, and lifelines. Air monitoring requirements mandate initial testing and periodic monitoring (at least every 2 hours) of oxygen levels (19.5%-23.5%), LEL/LFL (under 10%), hydrogen sulfide (less than 10 ppm), and carbon monoxide (less than 35 ppm), with documentation of the air tester name, ID, instrument type, model, and serial number. The permit requires identification of all attendants (required for all confined space work except alternate entry) and authorized entrants with their ID numbers. An Entry Supervisor must authorize the permit by signing confirmation that all conditions are satisfied. The form includes an entry log tracking entrant names and entry/exit times, emergency contact phone numbers for ambulance, fire, safety, and rescue team, and a permit cancellation section documenting the reason for cancellation (time expired, work completed, or unexpected circumstances) with confirmation that all entrants have safely exited and the space is secured. A contractor debrief section requires documentation of post-entry debriefing with contractor representatives.
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Text version
VANIHCS CONFINED SPACE ENTRY PERMIT
Permit Date: Permit Start Time: Permit End Time:
Permit Issuer: Printed Name: Signature:
Job site location or description:
Purpose of entry:
Supervisor(s) in charge of crews: Type of crew (welding, plumbing, etc.) Cell Phone #:
Internal and External Communication procedures (including equipment):
Rescue procedures (also see emergency contact phone numbers at end of form):
REQUIREMENTS
COMPLETED
(Put N/A if item doesn’t apply)
DATE TIME
REQUIREMENTS
COMPLETED
(Put N/A if item doesn’t apply)
DATE TIME
Lockout/Tagout Supplied Air Respirator
Line(s) Broken-Capped-Blank Respirator(s) (Air Purifying)
Purge-Flush and Vent Protective Clothing
Ventilation Full Body Harness w/ “D” ring
Secure Area (Post and Flag) Emergency Escape Retrieval Equip
Lighting (Explosive Proof) Lifelines
Hotwork Permit PPE
Fire Extinguishers
AIR MONITORING
Initial Monitoring Permissible Levels Periodic Monitoring
Time monitored:
Time (at least every
2 hours)
Percent Oxygen
19.5% to 23.5%
LEL/LFL Under 10% H2S <10 ppm CO <35 ppm
Air Tester Name ID# Instrument(s) Used Model # or Type Serial# or Unit
ATTENDANTS AND ENTRANTS
Attendant(s)
(Required for all confined space work except alternate entry)
ID# Authorized Confined Space Entrant(s) ID#
REMARKS:
ENTRY SUPERVISOR AUTHORIZATION - ALL CONDITIONS SATISFIED
Name and Signature: ______________________________________________ Date: ___________________
Department or phone number:
EMERGENCY CONTACT PHONE NUMBERS:
AMBULANCE: FIRE: SAFETY: RESCUE TEAM: OTHER:
ENTRY LOG
Entrant Name Time In Time Out Time In Time Out
PERMIT CANCELLATION
Reason: Time Expired Work Completed Unexpected:
Date Cancelled: Time Cancelled:
All Entrants have safely exited the space and are accounted for. The space is secured and will not be entered again under this permit. The permit will be returned to the EHS department for review and retention.
There were were not problems encountered during this entry (check one).
Cancelled By: Printed Name: Signature:
CONTRACTOR DEBRIEF (attach more sheets if necessary) The contractor debrief was held (date and time):
Name of Contractor and/or Representative Signature
| REQUIREMENTS COMPLETED |
| REQUIREMENTS COMPLETED |
| (Put N/A if item doesn’t apply) |
| (Put N/A if item doesn’t apply) |
| AIR MONITORING |
| Permissible Levels |
| Periodic Monitoring |
| Time monitored: |
| Time (at least every 2 hours) |
| Percent Oxygen |
| 19.5% to 23.5% |
| LEL/LFL |
| Air Tester Name |
| ID# |
| Instrument(s) Used |
| Model # or Type |
| Serial# or Unit |
| Initial Monitoring |
| ATTENDANTS AND ENTRANTS |
| Authorized Confined Space Entrant(s) |
| ID# |
| ID# |
| ENTRY LOG |
| Time Out |
| Time In |
| Time Out |
| Time In |
| Entrant Name |
| PERMIT CANCELLATION |
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