Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • SPACE / EQUIPMENT IDENTIFIER

SECTION ONE: If all three are checked, it is a Confined Space and you must proceed to Section 2. If it is not a Confined Space, proceed to Section 3

  • Is the space large enough and so configured that an employee can bodily enter and perform assigned work?

  • Are there limited means of entry or exit?

  • Is NOT designated for continuous employee occupancy?

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

  • Is there a potential for an atmospheric hazard?

  • Is there a potential for an engulfment hazard?

  • Is the space so configured that it poses a hazard?

  • Is there any other recognized 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 (<PEL) required?

  • 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?

SECTION 3: COMMENTS / ADDITIONAL INFORMATION

  • NOT a Confined Space

  • Non-Permit Required Confined Space

  • Permit Required Confined Space

  • 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:

  • Survey Conducted By:

  • Select date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.