Confined space entry permit template: base template and example

When you need an entry permit

• Safe Work Australia's confined spaces code says a written entry permit, completed by a competent person, is needed before anyone enters a confined space.
• Not every tank or pit is a confined space. The code explains how to tell: the space is enclosed, isn't designed for people to work in, and has risks such as an unsafe atmosphere or engulfment.
• Rules vary by state and territory, and several have their own confined spaces code. See what applies in each state below.

Need a SWMS for the work too? See the confined space SWMS example.

Entry permit rules in your state

Every state requires a written entry permit, but several states and territories have their own confined spaces code that sets out what goes on it. We're not a regulator, so check yours:

• Victoria: the entry permit requirement sits in the state's OHS Regulations. See WorkSafe Victoria's compliance code: Confined spaces

• Queensland: WorkSafe Queensland's Confined spaces Code of Practice 2021

• Western Australia: WorkSafe WA's confined spaces code of practice

• Australian Capital Territory: an updated code was approved in 2025. See the ACT approval notice

• Northern Territory: NT WorkSafe's confined spaces code

• New South Wales: SafeWork NSW

• South Australia: SafeWork SA

• Tasmania: WorkSafe Tasmania

The national model code is Safe Work Australia's confined spaces code of practice

Controls to think about

• Safe Work Australia's confined spaces code sets a safe atmosphere as oxygen between 19.5% and 23.5%, flammable gas below 5% of the lower explosive limit, and other contaminants below their exposure limits.
• Keep the permit current. The code says to re-check it if the work stops for a while, the person in control changes, or new hazards come up.
• Isolate the space from inflows and moving parts, ventilate it, and have a standby attendant and rescue plan in place. The standby attendant should never go in to rescue.

Hazards that change once people are inside

A permit records conditions at the start, but a confined space can change during the job. These are the changes that often get missed, with the kind of control the permit should show for each:

• Gas layering: heavier gases such as hydrogen sulphide sit low and lighter ones such as methane sit high. Test at the top, middle and bottom, not just at the opening.

• A detector that isn't reading properly: bump test it before use, check its calibration date, and record the detector ID on the permit.

• The work itself changing the air, such as welding, coatings, cleaning chemicals or disturbed sludge: keep monitoring and re-test after each change.

• Rain, process flows or a valve opened elsewhere on site: confirm inflows are blanked or locked out, and watch the weather.

• The standby attendant called away or swapped over: name a replacement on the permit before the first person leaves.

• Losing contact with the people inside: agree how you'll communicate, test it before entry, and set a regular check-in.

• Heat and fatigue building up over time: set maximum times inside and rest breaks on the permit.

• A long break or shift change: re-test the atmosphere and re-check controls before anyone goes back in.

What to include in a confined space entry permit

• The site, date, space and the times the permit is valid
• Gas test results for oxygen, flammable gas, CO and H2S, with times
• The hazards, such as engulfment, toxic gas or restricted entry and exit
• Controls checked, including isolation, ventilation, communication and rescue equipment
• An entry log of who went in and out, and when
• Sign-off by the entry supervisor and the standby attendant

Common gaps in a confined space entry permit

Before anyone goes in, check the permit doesn't have these gaps. Your site's confined space procedure may ask for more:

• Gas readings are recorded without a time, where they were taken, or which detector was used.

• The entry log doesn't match who's actually inside, or nobody signs out.

• The rescue equipment is ticked but nobody has checked it's set up at the opening.

• The permit is still open from yesterday, or was never closed once everyone was out.

• The permit doesn't name the person who issued it, or they aren't competent for that space.

Filled-in confined space entry permit example

Example only, not for use as your own permit. This is the base template filled in for a fictional job: two fitters entering a mixing tank to repair the agitator seal. Click the page to enlarge it.

Your own permit must be completed by a competent person for your actual space and job. Keep it until the work is done, or for at least 2 years if there's a notifiable incident.

How to fill one in

1. Fill in the site, date, space and the times the permit is valid.
2. Test the atmosphere before entry and at set times during the work, and record each result.
3. Tick the hazards, and confirm each control is in place before anyone enters.
4. Record everyone going in and out in the entry log.
5. Have the entry supervisor and standby attendant sign it, and close it out once everyone is out.

Get your confined space entry permit into the app

This form is in the Shadow Forms app. Your team can fill it in on site, add photos and sign it, then send it straight to the office.

The PDF and Word versions are copies only. If you have your own branded version, or want this one adjusted to your business, we can add it to the app. Upload a form, or get in touch.

Isolating plant before entry? Get the free lockout tagout permit template.

Running a bigger job? Get the free permit to work template.