Is the space large enough for an employee to bodily enter and perform work?

Are there limited means of entry or exit?

Is it NOT designated for continuous occupancy?

Is there a potential for an atmospheric hazard?

Is there a potential for an engulfment hazard?

Is the space so configured that it poses a hazard?

Is there any other recognized hazard (not listed here)? If Yes, list.

Oxygen Deficiency (<19.5%)?

Flammable Materials?

Toxic Substances?

OTHER Hazard? If Yes, List.

Monitoring Equipment Required? If Yes, List.

Ventilating Equipment Required? If Yes, List.

Communication Equipment Required? If Yes, List.

Is a Rescue Team on site?

Is an Off-Site Rescue Team on Standby? If Yes, list who & where.

Is a retrieval system required and/or available?

Are wristlets required and/or available?

Is a Tripod & safety harness required and/or available?

Are Communication Devices Required and/or available?

Is an Emergency Call list available?

OTHER requirement not identified? If Yes, List.

Is there a potential for Flowable Materials?

Are Hard Hats required and/or need to be available?

Is Eye Protection required and/or needs to be available? If REQUIRED, list type(s).

Is Hearing Protection required and/ or needs to be available? If REQUIRED, list type(s).

Are Gloves required and/or needs to be available? IF REQUIRED, list type(s).

Is special Safety Footwear required and/or needs to be available? If REQUIRED, list type(s).

Is Respiratory Protection required and/or needs to be available? If REQUIRED, list type(s).

Is Special Clothing required and/or needs to be available? If REQUIRED, list type(s).

Are there downward sloping floors?

Are there inwardly converging walls?

Is Special Lighting required and/or needs to available? If REQUIRED, list type(s).

Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).

Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).

Are Ladders required and/or needs to be available? If REQUIRED, list type(s).

Are SDS (Safety Data Sheets) required and/or needs to available?

Is cleaning or purging required?

Is Ventilation required and/or needs to be available? If REQUIRED, list type(s).

Is Isolation and/or Block & Bleed required?

Is Testing and/or Monitoring - Oxygen (19.5 - 23.5%) required?

Is Testing and/or Monitoring - Flammable (<10% LEL) required?

Is Testing and/or Monitoring - Toxics (

Review of applicable SDS (Safety Data Sheets) required?

Is a HOT WORK PERMIT required?

Are there Mechanical Hazards? If Yes, list.

Are there Electrical Hazards? If Yes, list.

Are there Wet/Slippery Conditions? If Yes, Explain.

Are there Heat and/or Cold Safety Concerns? If Yes, Explain.

Is there a potential for Reduced Visibility? If Yes, Explain.

Is there a Noise Concern? If Yes, Explain.

Can the space be locked or sealed?

Is it possible to eliminate all the hazards without anyone entering the space?

Permanently?

Concur

Concur

Concur

Concur

Concur