CONFINED SPACE ASSESSMENT FORM

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

• Purpose for entry?

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

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

  No

  Yes

• Are there limited means of entry or exit?

  No

  Yes

• Is it NOT designated for continuous occupancy?

  No

  Yes

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

• Is there a potential for an atmospheric/ chemical hazard?

  No

  Yes

• Is there a potential for an engulfment hazard?

  No

  Yes

• Is there electrical hazard?

  No

  Yes

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

• 4 gas meter needed? Select possibility

  No

  Yes

• Select Co H2S LEL O2

  • Co
  • H2S
  • LEL
  • O2

• Ventilating Equipment Required? If Yes select one.

  No

  Yes

• Select Natural Mechanical

  • Natural
  • Mechanical

• Communication type.

  No

  Yes

• Select Voice Radio Lifeline

  • Voice
  • Radio
  • Lifeline

• Is a Rescue Team on site?

  No

  Yes

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

  No

  Yes

• Rescue tripod needed?

  No

  Yes

• OTHER requirement not identified? If Yes, List.

  No

  Yes

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

• Is there a potential for Flowable Materials?

  No

  Yes

• Is Respiratory Protection required and/or needs to be available?

  Select Yes No

  • Yes
  • No

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

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

  Select Yes No

  • Yes
  • No

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

  Select Yes No

  • Yes
  • No

• Are GFCI's required?

  Select Yes No

  • Yes
  • No

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

  Select Yes No

  • Yes
  • No

• Is Arc rated harness needed?

  Yes

  No

• Type of access?

  Select Fixed ladder Extension Man hole hook ladder

  • Fixed ladder
  • Extension
  • Man hole hook ladder

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

• Are there Mechanical Hazards? If Yes, list.

  No

  Yes

• Are there Electrical Hazards? If Yes, list.

  No

  Yes

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

  No

  Yes

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

  No

  Yes

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

  No

  Yes

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

  No

  Yes

• OTHER Hazardous Concern NOT listed?

Classification & Pictures

• Federal Classification

  Select Non-Permit Permit Required

  • Non-Permit
  • Permit Required

• MN Class

  Select 1A 1B 2 3 N/A

  • 1A
  • 1B
  • 2
  • 3
  • N/A

• Duration

  Select Shift Annual

  • Shift
  • Annual

• Photograph of Space #1 OPTIONAL

  Media

• Photograph of Space #2 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: