Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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SPACE / EQUIPMENT IDENTIFIER:
STEP ONE: Does the space meet all 3 criteria's? (If all three are checked it is a Confined Space)
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Is the space large enough for an employee to bodily enter and perform work?
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Are there limited means of entry or exit?
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Is it NOT designated for continuous occupancy?
STEP TWO: (If ANY one hazard is present, it's a "PERMIT-REQUIRED" Confined Space)
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Is there a potential for an atmospheric hazard?
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Is there a potential for an engulfment hazard?
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Is the space so configured that it poses a hazard?
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Is there any other recognized hazard (not listed here)? If Yes, list.
ATMOSPHERIC HAZARDS
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Oxygen (<19% or >23.5%)?
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Flammable Materials greater than 10% of the LEL (lower explosive limit)?
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Toxic Substances (H2S, CO, Etc.)?
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OTHER Hazards like welding or engine fumes? If Yes, List.
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Monitoring Equipment Required? If Yes, List.
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Ventilating Equipment Required? If Yes, List.
ENGULFMENT HAZARDS
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Is there a potential for Flowable Materials?
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Are Hard Hats required and/or need to be available?
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Is Eye Protection required and/or needs to be available? If REQUIRED, list type(s).
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Is Hearing Protection required and/ or needs to be available? If REQUIRED, list type(s).
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Are Gloves required and/or needs to be available? IF REQUIRED, list type(s).
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Is special Safety Footwear required and/or needs to be available? If REQUIRED, list type(s).
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Is Respiratory Protection required and/or needs to be available? If REQUIRED, list type(s).
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Is Special Clothing required and/or needs to be available? If REQUIRED, list type(s).
CONFIGURATION HAZARDS
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Are there downward sloping floors?
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Are there inwardly converging walls?
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Is Special Lighting required and/or needs to available? If REQUIRED, list type(s).
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Are Explosion-Proof or Spark-Proof Tools required and/or needs to be available? If REQUIRED, list type(s).
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Are GFCI's required?
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Is Special Electrical Personal Protective Equipment required and/or needs to be available? If REQUIRED, list type(s).
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Are Ladders required and/or needs to be available? If REQUIRED, list type(s).
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Are SDS (Safety Data Sheets) required?
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SDS reviewed by the crew?
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OTHER requirement NOT listed:
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Is cleaning or purging required?
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Is Ventilation required and/or needs to be available? If REQUIRED, list type(s).
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Is Isolation and/or Block & Bleed required?
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Is a HOT WORK PERMIT required?
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OTHER requirement NOT listed?
OTHER HAZARDS
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Are there Mechanical Hazards? If Yes, list.
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Are there Electrical Hazards? If Yes, list.
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Are there Wet/Slippery Conditions? If Yes, Explain.
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Are there Heat and/or Cold Safety Concerns? If Yes, Explain.
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Is there a potential for Reduced Visibility? If Yes, Explain.
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Is there a Noise Concern? If Yes, Explain.
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OTHER Hazardous Concern NOT listed?
RESCUE/ENTRY PROCEDURES
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Communication Equipment Required? If Yes, List.
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Is a Rescue Team on site?
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Is an Off-Site Rescue Team on Standby? If Yes, list who & where.
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Is a retrieval system required and/or available?
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Are wristlets required and/or available?
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Is a Tripod & safety harness required and/or available?
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Are Communication Devices Required and/or available?
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Is an Emergency Call list available?
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OTHER requirement not identified? If Yes, List.
Other
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Attendant identified and properly trained?
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Entrant(s) identified and trained?
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Atmospheric testing was completed prior to entry?
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is continuous monitoring required?
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Confined space signs posted at entrance(s)?
COMMENTS / ADDITIONAL INFORMATION
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Photograph of Space #1 OPTIONAL
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Photograph of Space #2 OPTIONAL
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Photograph of Space #3 OPTIONAL
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Photograph of Space #4 OPTIONAL
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SPECIAL REQUIREMENTS FOR NON-PERMITTED SPACES:
