Fillable Printable Confined Space Entry Permit
Fillable Printable Confined Space Entry Permit
Confined Space Entry Permit
GENERAL SERVICES ADMINISTRATIONGSA FORM 3625 (10-91)
CONFINED SPACE ENTRY PERMIT
1A. NAME OF EMERGENCY CONTACT1B. TELEPHONE NUMBER
2. SPECIFIC LOCATION OF SPACE3. DESCRIPTION OF SPACE
4. PURPOSE OF ENTRY
5. ENTRY
6. EXIT
A. DATE
A. DATE
B. TIME
B. TIME
7A. NAME OF SUPERVISOR IN CHARGE OF WORK 7B. TELEPHONE NUMBER8. NAME OF ENTRANT(S)
9. NAME OF ATTENDANT10. NAME OF CONFINED SPACE TESTER11. WELDING OR "HOT WORK" REQUIRED
YESNO
12. CONFINED SPACE TEST DATA
List specific tests made. Entry is prohibited if reading outside standard permissible entry level(PEL).
13A. NAME OF INSTRUMENT(S)
A. SUBSTANCE TESTED
B. PERMISSIBLE
LEVEL
C. READINGD. DATEE. TIME
OXYGEN (%)
% OF LOWER EXPLOSIVE LIMIT
CARBON MONOXIDE
>19.5 <22.0
10%
35 ppm
13B. TYPE(S) OF INSTRUMENTS
13C. IDENTIFICATION NUMBER(S)
13D. WHEN LAST CALIBRATED
14. SPECIAL REQUIREMENTS (Explain each "No" answer in Item 18)
YES
NOITEM
YESNOITEM
A. LOCKOUT - DE-ENERGIZE (Employee retains key)
B. SPACE PURGED
C. VENTILATION
D. AREA SECURED
E. BREATHING APPARATUS
F. RESUSCITATOR/INHALATOR
G. ESCAPE HARNESS
H. LIFELINE
I. FIRE EXTINGUISHER
J. LIGHTING
K. EMERGENCY TRIPOD
L. PROTECTIVE CLOTHING
M. LINE CAPPED OR BLANKED
N. RESPIRATOR
O.
P.
15. OTHER SPECIAL REQUIREMENTS (List each and status)
16A. SPECIFIC PROTECTIVE CLOTHING AND EQUIPMENT REQUIRED16B. RESPIRATOR
NEG. PRESS.
PAPR
SUPPLIED AIR
SCBA
17. COMMUNICATION PROCEDURES DURING ENTRY
18. ADDITIONAL COMMENTS/REMARKS
19. RESERVED FOR REGIONAL S&EM DIVISION/BRANCH
20. I CERTIFY THAT I HAVE READ AND UNDERSTOOD ALL OF THE REQUIREMENTS OF THE CONFINED SPACE ENTRY PROGRAM IMPLEMENTED BY MY GSA
FACILITY MANAGER. FURTHERMORE, I WILL COMPLY WITH ALL OF THESE CRITERIA.
ENTRANT
SIGN AND
DATE HERE
ATTENDANT
SIGN AND
DATE HERE
21. I CERTIFY THAT ALL OF THE ABOVE INFORMATION IS CORRECT AND THE SPACE ENTRANT AND ATTENDANT ARE FULLY COMPETENT TO PERFORM WORK
DESCRIBED IN THE ABOVE CONFINED SPACE.
SUPERVISOR
SIGN HERE
DATE
GSA FORM 3625 BACK (10-91)
INSTRUCTIONS
SPECIAL NOTICE 1:THE CONFINED SPACE ENTRY PERMIT IS NOT A PERMIT TO CONDUCT "HOT WORK" OPERATIONS
THAT ARE COVERED UNDER THE PROVISIONS OF THE OSHA STANDARD 29 CFR 1910, SUBPART Q-WELDING, CUTTING
AND BRAZING. FOR "HOT WORK" OPERATIONS, A SEPARATE PERMIT (GSA FORM 1755) IS REQUIRED. IF "HOT WORK"
WILL BE REQUIRED IN CONJUNCTION WITH THE CONFINED SPACE ENTRY TASK, BOTH PERMITS (GSA FORM 1755 AND
GSA FORM 3625) ARE REQUIRED.
SPECIAL NOTICE 2: CONFINED SPACE ENTRY IS PROHIBITED IF TEST DATA INDICATES AN UNSAFE OR UNHEALTHFUL
CONDITIONS IS PRESENT IN ANY FORM OR QUANTITY. IN SUCH CASES, CONTACT THE REGIONAL SAFETY AND
ENVIRONMENTAL MANAGEMENT DIVISION/BRANCH FOR INSTRUCTIONS.
Description
Item No.
1:List the EMERGENCY CONTACT (name and telephone number) in BOLD letters - the RED is preferred.
List the specific location of the confined space.2:
List the specific description of the confined space.
List the specific reason that entry into the confined space is necessary.
3:
4:
Show the date and the time entry into the confined space will be accomplished. If entry does not take place within 4
hours of schedule, breaks included, a new permit will be required. The permit shall be authorized for one-day entry only
and for no more than 4 hours per day for each employee.
5:
Show the date and the time the confined space work is to be completed. If the work is not completed within one hour of
the time shown, the entrant will be required to leave the space and explain the circumstances. If the work is to take more
than two hours over the time shown, a new permit is required.
6:
7A:List the name of the supervisor in charge of the confined space. This individual must be available at all times while the
confined space is occupied.
7B:List the telephone number of the person listed in Item 7A.
List the name of the person entering the confined space. If more than one entrant is authorized, each individual shall be
listed.
8:
List the name of the attendant.9:
List the name of the person conducting confined space tests. If the tester is a contractor, a business card or other
identification, and a copy of the contract specifying the contractor's responsibility should be attached to the form.
10:
If the response is "Yes", a completed copy of GSA Form 1755, Permit for Welding, Cutting or Brazing, must be posted
next to the Confined Space Entry Permit, both of which must be in a conspicuous location outside the confined space.
11:
12:List the specific tests made and the purpose. As minimum, testing of oxygen, lower explosive limits, and carbon
monoxide, must be accomplished. For other contaminants, the OSHA permissible exposure limits shall be used as the
permissible entry limits.
13A:List the instruments used for the tests. If more than one instrument is used, enter the required information on a separate
sheet of paper and attach it to the form.
Place an "X" in the appropriate box. If the response is "NO" to any item, the supervisor shall indicate the reason in Item
18.
14:
The supervisor shall list any additional requirements or precautions necessary for the confined space entry. An example
would be if testing is required every 30 minutes; or if monitoring is required at all times during space occupancy. If there
are no additional requirements, the entry will so state this fact.
15:
List the specific protective clothing and equipment required for the task. Check the type of respiratory protective device:
Neg. Press - negative pressure, PAPR - powered air purifying respirator, SCBA - self-contained breathing apparatus.
16A-16B:
State precisely what the communication procedures will be between the entrant and attendant during the confined space
entry period.
17:
18:The supervisor shall list use this space to indicate any exceptions, negative responses in Item 14, and any other remarks
necessary to ensure a safe and healthful confined space entry task is accomplished.
The regional S&EM office shall use this space to note any deficiencies on the entry permit or any other aspect of the
facility confined space entry program. Positive corrective measures are to be noted in this item and the facility manager
required to respond to any unfavorable comment.
19:
The entrant and attendant shall sign and date the form. They must sign on the date of entry into the confined space.20:
The supervisor must sign and date the authorization for the confined space entry. The supervisor must sign on the date
of entry. The supervisor shall not sign the form unless all items are completed. There shall not be any blank items
allowed for Items 1 through17.
21:
