75 ABW CONFINED SPACE ASSESSMENT WORKSHEET CHECKLIST

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:

Squadron:

Office Symbol

Commander/FM's Name and Grade:

DSN:

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:

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):

List recognized/known hazards:

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

How/Why?

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