JHA Template for Confined Space Entry
Project / Work Details
Project Name
Location
Date
Work Description
Personnel
Entry Supervisor
Entrant(s)
Attendant(s)
Rescue Personnel
Hazard Assessment
Step/Task
Potential Hazards
Controls / Mitigation
Atmospheric Testing
Test Type
Initial Reading
Periodical Reading
Oxygen (%)
LEL (%)
CO (ppm)
H
2
S (ppm)
PPE & Equipment Required
Emergency Procedures
Authorization & Signatures
Name
Role
Signature
Date
Entry Supervisor
Attendant
Entrant
Rescue Personnel