Confined Space Hazard Assessment

Space ID Number

• Description/Location of Space

• Conducted on

  Date
• Geo Location
  Address

• Pictures of space

  Media

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?

  Yes

  No

  N/A

• Are there limited means of entry or exit?

  Yes

  No

  N/A

• Is it NOT designated for continuous occupancy?

  Yes

  No

  N/A

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

• Is there a potential for an atmospheric hazard?

  Yes

  No

  N/A

• Oxygen Deficiency (<19%)?

  Yes

  No

  N/A

• Flammable Materials?

  Yes

  No

  N/A

• Hydrogen Sulfide (H2S)?

  Yes

  No

  N/A

• Toxic Substances?

  Yes

  No

  N/A

• OTHER Hazard? If Yes, List.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

• Are there downward sloping floors?

  Yes

  No

  N/A

• Are there inwardly converging walls?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are GFCI's required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• OTHER requirement NOT listed?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

OTHER HAZARDS / REQUIRED PPE and/or Equipment

• Are there Mechanical Hazards? If Yes, list.

  Yes

  No

  N/A

• Are there Electrical Hazards? If Yes, list.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Are Hard Hats required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Communication Equipment Required? If Yes, List.

  Yes

  No

  N/A

• Ventilation Required?

  Yes

  No

  N/A

• Is a Tripod & safety harness required?

  Yes

  No

  N/A

• Is a retrieval system required?

  Yes

  No

  N/A

• Are wristlets or tag line required?

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• OTHER Hazardous Concern NOT listed?

  Yes

  No

  N/A

Determination

• This space has been determined to be a:

  Select Permit Required Confined Space Non-Permit Required Confined Space

  • Permit Required Confined Space
  • Non-Permit Required Confined Space

• 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?

  Yes

  No

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

  Yes

  No

  N/A

SIGNATURES (e-SSS)

• Occupational Safety

  Sign

• Bioenvironmental (BE)

  Sign

• Fire Department (FES)

  Sign

• Unit Representative

  Sign