Confined Space Evaluation Form

• Site conducted

  Select

• Audit Title

• Client

• Conducted on

  Date

• Prepared by

• Space Location:

• Space Description

Is it a confined space?

• 1. Is the space large enough and shaped so an employee can enter and work?

  Yes

  No

  N/A

• 2. Does the space have a limited or restricted means for entry and exit?

  Yes

  No

  N/A

• Is the space NOT designed for continuous employee occupancy?

  Yes

  No

  N/A

If yes to all three above questions:

• Does the space contain, or have the potential to contain, a hazardous atmosphere, or pipes, ducts, vents or other entry points for potentially hazardous substances, or will volatile chemicals be used, or will painting or other work that could create a breathing hazard be performed?

  Yes

  No

  N/A

• Specify potential or known hazards:

• Does the space contain a material with the potential for engulfment of a worker?

  Yes

  No

  N/A

• Specify potential or known hazards:

• Does the space have an internal shape such that a worker could be trapped or suffocated by inwardly converging walls, floor or ceiling?

  Yes

  No

  N/A

• Specify potential or known hazards:

• Does the space contain other recognized safety or health hazards, such as mechanical hazards, energized equipment, gas or chemical lines, special hazards related to elevation or falling, or tempertaure extremes/heat stress? (List all that apply)

  Yes

  No

  N/A

• Specify potential or known hazards:

• Will welding, cutting, torch work, or other hot work be performed?

  Yes

  No

  N/A

• Specify potential or known hazards: