Confined Space Pre-Entry Checklist

Information

Conducted on
Prepared by
Competent Person- One who is capable of identifying existing and predictable hazards in the surroundings or working conditions which are unsanitary, hazardous, or dangerous to employees, and who has the authorization to take prompt corrective measures to eliminate them.
Ensure Confined Space (Permit or Non-Permit) is noted on the FOCUS form.
Location
Personnel

Confined Space Details

A confined space is a space that meets these criteria: 1) being large enough for an employee to enter and perform work; 2) has limited or restricted means for entry or exit; and 3) is not designed for continuous occupancy. A confined space requires a permit if a space may also: 1) contain a hazardous atmosphere; 2) contain material that has the potential to engulf an entrant; 3) has walls that converge inward or floors that slope downward and taper into a smaller area which could trap or asphyxiate an entrant; or 4) contains any other recognized safety or health hazard, such as unguarded machinery, exposed live wires, or heat stress.
Is a permit required for this space?
Date and time of entry
Description / Purpose of work
Specific Location on site
Identify potential hazards of this confined space? (select all that apply)
- Electrical
- Mechanical
- Hydraulic
- Pneumatic
- Radiation
- Temperature Extremes
- Engulfment
- Noise
- Chemical
- Pipelines
- Welding/Cutting
- Falls
- Obstructions
- Converging Surfaces
- Other 1:
- Other 2:
Describe other hazard(s)

Have all physical hazards been eliminated, isolated, or locked or blocked out?
Are there any existing or potential atmospheric hazards?
Will forced-air ventilation control the hazard?
Has the weather been checked for possible flash flooding?
Space ventilated to full extent possible?
All people involved have completed confined space training?
Vehicles and plants removed from confined space to reduce fume hazard? If not, have precautions been put in place?
Correct confined space signage in place?
Space lighting in place and appropriate?
Access (both entry and exit) points have been identified and are clear of hazards for use?
Communications plan defined and understood by all involved?
Select methods of communication to be adopted (select all that apply)
- Cell phone
- Two-way radio
- Rope signals
- Sounds
- Verbal communication
- Hand signals
- Other

Does the air of this confined space require monitoring?
Is the air of the confined space being continuously monitored? (as required)
Log air sample results
Time of sample
% Oxygen
% Flammable
%LEL
H2S
CO PPM
Is this sample within acceptable parameters? Should confined space work proceed?
Has monitoring equipment been calibrated?

Emergency evacuation and rescue plan is complete, in place and understood by all employees?
Emergency Number
Location of phone or radio
Emergency actions to be taken
Potential emergency situations

For the purpose of this entry THIS CONFINED SPACE IS :
- Permit-required -- the full permitting process must be implemented
- Alternate-procedure – continuous ventilation and gas monitoring must be used and all physical hazards must be eliminated or isolated.
- Non-permit – does not meet the requirements for permit-required.

Have all relevant personnel participated in pre-entry briefing?
Confined Space Entrants: We (I) have reviewed the potential emergency situations and actions to be taken. We (I) are familiar with all rescue equipment and communication methods. I have been formally trained in confined space entry.
Name and Signature (entrant to sign)
Confined Space Entry Supervisor: I have complete properly evaluated this confined space and verified that acceptable entry conditions exist. All personnel have reviewed the conditions of the entry and are adequately trained to perform this task. I have been formally trained in confined space entry.
Name and Signature (supervisor to sign)