Title Page
Space Number/Name
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Conducted on
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Prepared by which SEG Personnel
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Personnel Present
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Confined Space ID # (If already classified as a confined space):
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Location of Space(s):
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Add location
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Process/Item Name:
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Take a picture of the space:
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Squadron:
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Office Symbol
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Commander/FM's Name and Grade:
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DSN:
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1. Is the space large enough for an employee's whole body to enter?
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2. Are there limited/restricted openings making entry/egress difficult?
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3. Is the space designed for continuous human occupancy?
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4. Identify all that apply to the space:
- a. Has or "potential" to have a harmful atmosphere
- b. Contains material that has "potential" for engulfment (liquid, sand, saw dust, etc.)
- c. Internal configuration that "could" trap or asphyxiate an entrant (inward sloping walls, floors, etc.)
- d. Contains any recognized hazards (list):
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List recognized/known hazards:
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5. Is it possible to eliminate all the hazards without anyone entering the space?
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How/Why?
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6. How frequently will the space be entered?
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How Often?
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7. Location(s) and description of the space to be entered (If not specific enough above):
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8. Purpose of entry into the space
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9. Tasks or operations to be performed in the space: (attach separate list if more space is needed)
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Commander/FM Justification (Optional):
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Commander/FM Signature
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Date of Assessment
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Tenant/OSM Signature
