CONFINED SPACE ASSESSMENT FORM

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date
• Location
  Address

• SPACE / EQUIPMENT IDENTIFIER:

STEP ONE: (If all three are checked, it is a Permitted - Confined Space)

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are there limited means of entry or exit?

  Yes

  No

  N/A

• Is it NOT designated for continuous human occupancy?

  Yes

  No

  N/A

STEP TWO: (If ANY one hazard is present, it's a Tier 1 "PERMIT-REQUIRED" Confined Space)

• Is there a potential for an atmospheric hazard?

  Yes

  No

  N/A

• Is there a potential for an engulfment hazard?

  Yes

  No

  N/A

• Is the space so configured that it poses a hazard for entrapment by converging walls?

  Yes

  No

  N/A

• Is there any other recognized hazard (not listed here such as oxygen deficieny)? If Yes, list.

  Yes

  No

  N/A

ATMOSPHERIC HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES

• Oxygen Deficiency (<19%)?

  Yes

  No

  N/A

• Flammable Materials?

  Yes

  No

  N/A

• Monitoring Equipment Required? If Yes, List.

  Yes

  No

  N/A

• Ventilating Equipment Required? If Yes, List.

  Yes

  No

  N/A

• Communication Equipment Required? If Yes, List.

  Yes

  No

  N/A

• Is a retrieval system required and/or available?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

CONFIGURATION HAZARDS ......................REQUIRED PPE and/or Equipment.......................RESCUE/ENTRY PROCEDURES

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

  Yes

  No

  N/A

• Are MSDS (Material Safety Data Sheets) required and/or needs to available?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Is cleaning or purging required?

  Not Required

  REQUIRED

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

• Is Testing and/or Monitoring - Toxics (<PEL) required?

  Yes

  No

  N/A

• Does this fall into a Tier 1 or a Tier 2 confined space?

  Tier 1

  Tier 2

COMMENTS / ADDITIONAL INFORMATION

• Photograph of Space #1 OPTIONAL

  Media

• Photograph of Space #2 OPTIONAL

  Media

• Photograph of Space #3 OPTIONAL

  Media

• Photograph of Space #4 OPTIONAL

  Media

NAME & SIGNATURE OF PERSON CONDUCTING ASSESSMENT

• Add signature

  Sign

• Yes

  No

  N/A