UM Confined Space Permit

Appendix II
UM Confined Space Permit

The following permit has been designed to assist in protecting persons entering confined spaces. It shall be completed before any University of Maryland employee enters a space designated as a "Permit-Required Confined Space". Only individuals that have received Confined Space Training shall be authorized to complete this permit. All questions that are not applicable to the entry are to be answered as "N/A". If questions arise concerning the contents of this form or specific hazardous conditions, please consult your immediate supervisor or the Department of Environmental Safety (301) 405-3960.

This section is to be completed by the confined space entry supervisor.

Identification Location__________________________________________________________________________________________________________________________________

Date:

Expiration Date:

Time: am pm

Expiration Time: am pm

Note: This Permit is valid for one entry team during a single entry. Maximum duration of the permit will be 8 hours . All copies shall remain at the job site until work has been completed.
Description of Space:
______________________________________________________________________________________________________________________________________________________________________
Reason for entry: (e.g., welding, cleaning, etc.)___________________________________________________________________________________

Authorized Personnel

Entrants Attendants Contractors

Equipment Required

What type of communication equipment will be used to maintain contact with entrants? ( ) radio ( ) phone ( ) visual contact ( ) other ____________
What type of communication equipment will be available to contact emergency services? ( ) radio ( ) phone
Is respiratory protective equipment required for this job? ( )Yes ( )No
    If yes, has each member of the entry team completed respirator training, physicals and fit testing? ( )Yes ( )No
    If yes, what type? ( ) SCBA ( ) supplied air ( ) PAPR ( ) full face ( ) half mask    cartridge used: ______________________________________________
Is personal protective clothing required for this job? ( )Yes ( )No If yes, What type?
( ) coveralls        ( ) splash suit    ( ) leather gloves    ( ) chemical gloves    ( ) goggles        ( ) face shield    ( ) ear plugs ( ) other_________
( ) ear muffs       ( ) hard hat        ( ) welding hood    ( ) welding gloves    ( ) welding jacket    ( ) safety boots    ( ) chemical boots
What types of hazardous energy may be present?
( ) electrical        ( ) mechanical    ( ) hydraulic        ( )chemical         ( )pneumatic        ( ) thermal
How will these hazards be eliminated or controlled?
____________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

What other hazards may the worker be exposed to?
____________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________

Supervisor's Name (Print)__________________________________ Signature_____________________________________ Date_____________

This section is to be completed by the attendant.
Atmospheric Testing

Type of gas monitor___________________________________________________ Date of last calibration________________________________

	Initial	#2	#3	#4	#5	#6	# 7	#8	#9	#10
Oxygen (between 19.5% and 23.5%)
Flammables/combustibles (less than 10% of L.E.L.)

Toxic Contaminants

Chemical Name (Is the MSDS present?)

MSDS

PEL

#10

This Permit Must Be Posted Near the Entrance of the Space During Entry
This Entry Must be Registered With Facilities Management Work Control at (301) 405-2222 Prior to Entry
Original Form Must be Forwarded to the Department of Environmental Safety Upon Completion of the Entry

Additional Requirements

Check List (Initial the appropriate box)

YES NO N/A

All warning/caution signs, barricades, etc. are posted and in place.

Hazardous energy has been locked and tagged.

An emergency escape plan has been developed.

Safety life lines and retrieval system are secured and in place,

Space has been properly ventilated.

Required personal protective equipment is available and in use.

Entry has been registered with FM Work Control at (301) 405-2222.

Permit Has Been Revoked By____________________________________Reason___________________________________________________Date_____________

Entrant #1 Signature____________________________Date____________ Entrant #2 Signature____________________________Date____________

Entrant #3 Signature____________________________Date____________ Entrant #4 Signature____________________________Date____________

Attendant #1 Signature__________________________Date_____________ Attendant #2 Signature_________________________Date_____________

In Case of Emergency
Call 9-1-1
Or Radio FOR Help

Identify the space you are entering in words that could identify your location to off campus responders:

_____________________________________________________________________________________________________________________

This Permit Must Be Posted Near the Entrance of the Space During Entry
This Entry Must Be Registered With Facilities Management Work Control at (301) 405-2222 Prior to Entry
Original Form Must Be Forwarded to the Department of Environmental Safety
Upon Completion of the Entry

Comments:_____________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

Rev date 11/95

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Check List	(Initial the appropriate box)
Check List	YES	NO	N/A
All warning/caution signs, barricades, etc. are posted and in place.
Hazardous energy has been locked and tagged.
An emergency escape plan has been developed.
Safety life lines and retrieval system are secured and in place,
Space has been properly ventilated.
Required personal protective equipment is available and in use.
Entry has been registered with FM Work Control at (301) 405-2222.

Appendix IIUM Confined Space Permit

Appendix II
UM Confined Space Permit