D2C Confined Space Checklist v1.1

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

A. Confined Space Entry Program

• 1. Workplace survey complete

  Yes

  No

  N/A

• 2. Written program complete

  Yes

  No

  N/A

• 3. Training complete and documented

  Yes

  No

  N/A

• 4. Periodic survey of canceled permits performed and documented

  Yes

  No

  N/A

B. Confined Space Entry Procedures

2. Entry procedures established and documented for:

• a. permit-required confined spaces (permit spaces)

  Yes

  No

  N/A

• b. alternate procedures for permit spaces

  Yes

  No

  N/A

• c. non-permit confined spaces

  Yes

  No

  N/A

• 3. Protective equipment and materials provided and maintained

  Yes

  No

  N/A

• 4. Rescue and Emergency Services provided for

  Yes

  No

  N/A

• 5. Procedures established for work performed by contractors in confined spaces

  Yes

  No

  N/A

• Summary of Findings

• Please sign upon audit completion

  Sign