Confined Space ID # (If already classified as a confined space):

Location of Space(s):

Add location

Process/Item Name:

Take a picture of the space:


Office Symbol

Commander/FM's Name and Grade:


1. Is the space large enough for an employee's whole body to enter?

2. Are there limited/restricted openings making entry/egress difficult?

3. Is the space designed for continuous human occupancy?

4. Identify all that apply to the space:

List recognized/known hazards:

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


6. How frequently will the space be entered?

How Often?

7. Location(s) and description of the space to be entered (If not specific enough above):

8. Purpose of entry into the space

9. Tasks or operations to be performed in the space: (attach separate list if more space is needed)

Commander/FM Justification (Optional):

Commander/FM Signature
Date of Assessment
Tenant/OSM Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.