Space ID Number
  • Description/Location of Space

  • Conducted on

  • Geo Location
  • Pictures of space


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

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

  • Are there limited means of entry or exit?

  • Is it NOT designated for continuous occupancy?

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

  • Is there a potential for an atmospheric hazard?

  • Oxygen Deficiency (<19%)?

  • Flammable Materials?

  • Hydrogen Sulfide (H2S)?

  • Toxic Substances?

  • OTHER Hazard? If Yes, List.

  • Is there a potential for an engulfment hazard? If Yes, List.

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

  • Are there downward sloping floors?

  • Are there inwardly converging walls?

  • Is Special Lighting required? If REQUIRED, list type(s).

  • Are Explosion-Proof or Spark-Proof Tools required? If REQUIRED, list type(s).

  • Are GFCI's required?

  • Is Special Electrical Personal Protective Equipment required? If REQUIRED, list type(s).

  • Are Ladders required and/or needs to be available? If REQUIRED, list type(s).

  • OTHER requirement NOT listed?

  • Is there any other recognized hazard (not listed here)? If Yes, list.


  • Are there Mechanical Hazards? If Yes, list.

  • Are there Electrical Hazards? If Yes, list.

  • Are there Thermal Stress Safety Concerns? If Yes, Explain.

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

  • Is special Safety Footwear required? If REQUIRED, list type(s).

  • Are Gloves required? IF REQUIRED, list type(s).

  • Are Hard Hats required?

  • Is Respiratory Protection required? If REQUIRED, list type(s).

  • Is Eye/Face Protection required? If REQUIRED, list type(s).

  • Is Special Clothing required? If REQUIRED, list type(s).

  • Communication Equipment Required? If Yes, List.

  • Ventilation Required?

  • Is a Tripod & safety harness required?

  • Is a retrieval system required?

  • Are wristlets or tag line required?

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

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

  • OTHER Hazardous Concern NOT listed?


  • This space has been determined to be a:

  • Is the space well ventilated and entered on a weekly basis and can a visual review prior to entry determine if a changed condition in or around the space could have introduced an atmospheric or other non-visual hazard?

  • Is atmospheric testing required before entry into the Non-Permit space?

CSPT Review


  • Occupational Safety

  • Bioenvironmental (BE)

  • Fire Department (FES)

  • Unit Representative

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.