Audit

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?

Are there limited or restricted means of entry or exit?

Is space NOT designed for continuous occupancy?

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?

Contains a material that has potential to engulf an entrant?

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

Contains any other recognized serious safety or health hazard? (not listed here) If Yes, list.

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

Oxygen Deficiency (<19%)?

Flammable Materials?

Toxic Substances?

OTHER Hazard? If Yes, List.

Monitoring Equipment Required? If Yes, List.

Ventilating Equipment Required? If Yes, List.

Communication Equipment Required? If Yes, List.

Is a Rescue Team on site?

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

Is a retrieval system required and/or available?

Are wristlets required and/or available?

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

Are Communication Devices Required and/or available?

Is an Emergency Call list available?

OTHER requirement not identified? If Yes, List.

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

Is there a potential for Flowable Materials?

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

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

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

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

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

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

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

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

Are there downward sloping floors?

Are there inwardly converging walls?

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

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

Are GFCI's required?

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

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?

OTHER requirement NOT listed:

Is cleaning or purging required?

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

Is Isolation and/or Block & Bleed required?

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 (

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

Is a HOT WORK PERMIT required?

OTHER requirement NOT listed?

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

Are there Mechanical Hazards? If Yes, list.

Are there Electrical Hazards? If Yes, list.

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

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

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

Is there a Noise Concern? If Yes, Explain.

OTHER Hazardous Concern NOT listed?

COMMENTS / ADDITIONAL INFORMATION
Photograph of Space #1 OPTIONAL
Photograph of Space #2 OPTIONAL
Photograph of Space #3 OPTIONAL
Photograph of Space #4 OPTIONAL

SPECIAL REQUIREMENTS FOR NON-PERMITTED SPACES:

Entrants and Attendants

Entrant(s)?

Entrant(s) Signature

Attendant?

Attendant's Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.