CONFINED SPACE ASSESSMENT FORM CHECKLIST

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?

Are there limited means of entry or exit?

Is it NOT designated for continuous human occupancy?

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?

Is there a potential for an engulfment hazard?

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

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

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

Oxygen Deficiency (<19%)?

Flammable Materials?

Monitoring Equipment Required? If Yes, List.

Ventilating Equipment Required? If Yes, List.

Communication Equipment Required? If Yes, List.

Is a retrieval system required and/or available?

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

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

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

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

Is cleaning or purging required?

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

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

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

Is Testing and/or Monitoring - Toxics (

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

COMMENTS / ADDITIONAL INFORMATION

Photograph of Space #1 OPTIONAL

Photograph of Space #2 OPTIONAL

Photograph of Space #3 OPTIONAL

Photograph of Space #4 OPTIONAL

NAME & SIGNATURE OF PERSON CONDUCTING ASSESSMENT

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