Confined Space Assessment

• Conducted on

  Date

• Prepared by

• Location
  Address

• Confined Space identification

• Type of space

• Photo of space

  Media

AS 2865-2009 - Confined spaces

• Is the space enclosed or partially enclosed?

  Enclosed

  Partially Enclosed

• Is not designed or intended primarily to be occupied by a person?

  Yes

  No

• Is, or is designed or intended to be, at normal atmospheric pressure while any person is in the space?

  Yes

  No

• An oxygen concentration outside the safe oxygen range

  Yes

  No

• A concentration of airborne contaminants that may cause impairment, loss of consciousness, or asphyxiation.

  Yes

  No

• A concentration of flammable airborne contaminants that may cause injury from fire or explosion.

  Yes

  No

• Engulfment in a stored free-flowing solid or a rising level of liquid that may cause suffocation or drowning.

  Yes

  No

• This Space can be classified as :

  Select Confined Space Restricted Space Non - Confined Space

  • Confined Space
  • Restricted Space
  • Non - Confined Space

Details of the Space

• Types of works being undertaken within space

• Entry type: "add photo"

  Door

  Hatch

• Number of Entrances:

• Access type: "add photo"

  Stairs

  Horizontal - Crawl space

  Ladder

  Vertical - Lowering system

• Photo of Inside the Space

  Media

• Hazards: "add photo"

  Select Slips trips and falls Egulfment Constrained movement Biological Entrapment Atmospheric

  • Slips trips and falls
  • Egulfment
  • Constrained movement
  • Biological
  • Entrapment
  • Atmospheric

• Signage: "add photo"

  Present

  Absent

• Additional Comments

Entry provisions

• Atmospheric Testing Required:

  Yes

  No

• Atmospheric Testing Type:

  Once off

  Continuous Gas Testing

• Ventilation Required:

  Yes

  No

• Ventilation System

  Select Natural Positive Pressure Negative Pressure Positive and Negative Pressure

  • Natural
  • Positive Pressure
  • Negative Pressure
  • Positive and Negative Pressure

• Lock out, Tag out Required:

  Yes

  No

• Entry Equipment Requirements:

  Select Hard Hat Bump Cap Safety Glasser's Safety Goggles P2 Dust mask Half Face Respirator Full Face Respirator Positive Pressure Respirator Self Contained Breathing Apparatuses Gas Detector Tripod Winch Rope lowering system Ladder Self Retracting lanyard Safety System Harness Lanyards Radios Communication

  • Hard Hat
  • Bump Cap
  • Safety Glasser's
  • Safety Goggles
  • P2 Dust mask
  • Half Face Respirator
  • Full Face Respirator
  • Positive Pressure Respirator
  • Self Contained Breathing Apparatuses
  • Gas Detector
  • Tripod
  • Winch
  • Rope lowering system
  • Ladder
  • Self Retracting lanyard Safety System
  • Harness
  • Lanyards
  • Radios Communication

• Rescue Plan Required:

  Yes

  No