CONFINED SPACE ASSESSMENT FORM

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• SPACE / EQUIPMENT IDENTIFIER:

STEP ONE: If all three are checked, it is a "Confined Space"

• Is space large enough for an EE to bodily enter and perform assigned work?

  Yes

  No

  N/A

• Are there limited or restricted means of entry or exit?

  Yes

  No

  N/A

• Is space NOT designed for continuous occupancy?

  Yes

  No

  N/A

STEP TWO: If ANY following hazard is present, it is a "PERMIT-REQUIRED Confined Space"

• Contains or has the potential to contain a hazardous atmosphere?

  Yes

  No

  N/A

• Contains a material that has potential to engulf an entrant?

  Yes

  No

  N/A

• Is the space so configured that it poses a hazard?<br>-inwardly converging walls?<br>-floor which slopes downward and tapers to a smaller cross-section?

  Yes

  No

  N/A

• Contains any other recognized serious safety or health hazard? (not listed here) 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

• Toxic Substances?

  Yes

  No

  N/A

• OTHER Hazard? If Yes, List.

  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 Rescue Team on site?

  Yes

  No

  N/A

• Is an Off-Site Rescue Team on Standby? If Yes, list who & where.

  Yes

  No

  N/A

• Is a retrieval system required and/or available?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Are wristlets 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

• Are Communication Devices Required and/or available?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Is an Emergency Call list available?

  Yes

  No

  N/A

• OTHER requirement not identified? If Yes, List.

  Yes

  No

  N/A

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

• Is there a potential for Flowable Materials?

  Yes

  No

  N/A

• Are Hard Hats required and/or need to be available?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  TVA Standard Safety Shoe

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  FR

  N/A

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

• Are there downward sloping floors?

  Yes

  No

  N/A

• Are there inwardly converging walls?

  Yes

  No

  N/A

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

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Are GFCI's required?

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).

  Not Required

  REQUIRED

  AVAILABLE

  N/A

• 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

• OTHER requirement NOT listed:

• 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 Isolation and/or Block & Bleed required?

  Not Required

  REQUIRED

  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?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Review of applicable MSDS (Material Safety Data Sheets) required?

  Yes

  No

  N/A

• Is a HOT WORK PERMIT required?

  Yes

  No

  N/A

• OTHER requirement NOT listed?

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

• Are there Mechanical Hazards? If Yes, list.

  Yes

  No

  N/A

• Are there Electrical Hazards? If Yes, list.

  Yes

  No

  N/A

• Are there Wet/Slippery Conditions? If Yes, Explain.

  Yes

  No

  N/A

• Are there Heat and/or Cold Safety Concerns? If Yes, Explain.

  Yes

  No

  N/A

• Is there a potential for Reduced Visibility? If Yes, Explain.

  Yes

  No

  N/A

• Is there a Noise Concern? If Yes, Explain.

  Yes

  No

  N/A

• OTHER Hazardous Concern NOT listed?

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

• SPECIAL REQUIREMENTS FOR NON-PERMITTED SPACES:

Entrants and Attendants

• Entrant(s)?

• Entrant(s) Signature

  Sign

• Attendant?

• Attendant's Signature

  Sign